THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


CLINICAL  LESSONS 


T^ERVOUS  DISEASES 


BY 


S.  WEIR  MITCHELL,  M.D.,  LL.D.  Edin. 

MEMBER  OF  THE  NATIONAL   ACADEMY  OF  SCIENCES  ; 
HONORARY  FELLOW  OF  THE  ROYAL  MEDICO-CHIRURGICAL  SOCIETY   OF  LONDON 


LEA  BROTHERS  &  CO. 

PHILADELPHIA   AND   NEW   YOEK 
1897 


Entered  according  to  the  Act  of  Congress,  in  the  year  1897,  by 

LEA  BEOTHERS  &  CO., 

In  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


DORNAN    TRINTKR. 


lOO 
PREFACE 


I  TAKE  this  opportunity  to  thank  my  clinical 
aids,  Drs.  John  Madison  Taylor,  C.  W.  Burr,  Guy 
Hinsdale,  John  K.  Mitchell,  John  H.  Rhein,  F.  S. 
Pearce,  A.  A.  Eschner,  and  F.  W.  Talley  for  the 
careful  personal  study  given  to  the  cases  in  this  little 
book  and  for  whatever  consequent  value  they  may 
have.  I  am  also  indehied  to  Dr.  John  Madison 
Taylor  for  the  representations  of  erythromelalgia  and 
for  the  other  illustrative  drawings. 

S.  AY.  M. 


erT5[v98 


CONTENTS 


CHAPTER   I. 

PAGE 

Hysteria:   Psychic  Anresthesia  for  Touch ;  Psychic  Anosmia; 

Psychic  Blindness     .         .         .         .         .         .         .         .13 

CHAPTER   II. 

Recurrent  Melancholia:  Seasonal  Melancholia;  Melancholia 
arising  out  of  Menstruation ;  Inter-menstrual  Melan- 
cholia ;  Melancholia  arising  out  of  Dreams  or  Originating 
in  the  Post-dormitium  ;  Melancholia  during  Digestion     .       25 

CHAPTER   III. 

Irregularly  Recurrent  Melancholia  with  Short  Intervals  and 

not  in  Apparent  Relation  to  Function       ....       53 

CHAPTER   IV. 

Some  Disorders  of  Sleep  .......      58 

CHAPTER   V. 

Choreoid  Movements  in  an  Adult  Male,  probahly  of  Hysteri- 
cal Origin  ;  Unusual  Hysterical  Movements  in  a  Child  ; 
Hysterical  Myoclonus 94 

CHAPTER   VI. 

Subjective  False  Sensations  of  Cold 107 


VI 


CONTENTS. 


CHAPTER   Vir. 

PAGE 

Motor  Ataxia  in  a  Child  of  Three  Years,  with  Retained 
Muscle-reflexes ;  Pernicious  Anaemia,  with  Locomotor 
Ataxia  and  Hysteria  .         .         .         .         .         .         .125 

CHAPTER    VIII. 

Post-hemiplegic  Pain  ;  Prse-hemiplegic  pain  ;  Post-hemiplegic 

Disease  of  Joints ;  Post-hemiplegic  Xodes        .         .         .     145 

CHAPTER    IX. 
The  Treatment  of  Sciatica       .         .         .         .  .154 

CHAPTER    X. 

Erythromelalgia:  Red  Xeuralgia  of  the  Extremities  ;  Vaso- 
motor Paralysis  of  the  Extremities;  Terminal  Xeuritis    .     177 

CHAPTER   XI. 

Xotes  on  Surface-temperatures  as  Affected  by  Posture  of  Limbs     205 

CHAPTER   XII. 

Three  Cases  of  Remarkable  Spinal  Anterior  Curvature  with 

Mental  Aberration    .         .  .         .         .  .210 

CHAPTER    XIII. 

Concerning  the  History  of  the  Discovery  of  Reflex  Ocular 

Neuroses,  and  the  Extent  to  which  these  Reflexes  Obtain     220 

CHAPTER   XIV. 
Wrong  Reference  of  Sensations  of  Pain  .         .         .         .         .231 


CONTENTS.  yii 


CHAPTER   XV. 

PAGE 

Pseiictocyesis ;  Spurious  Pregnancy ...  .         .     236 


CHAPTEE   XVI. 

Hysterical  Contractures .         .     242 

CHAPTER   XVII. 

Hysterical  Contractures  [Continued)         •         •  .         .     275 

CHAPTER   XVIII. 

Rotatory  Movements  in  the  Feeble-minded     ....     290 


ERRATUM 


Page  53,  in  chapter  heading,  /o/-  '' mehincholia  with  long  inter- 
vals," read  "  melancholia  with  short  intervals." 


CLINICAL   LESSONS 


ON 


NERVOUS   DISEASES. 


CHAPTER   I. 

HYSTEEIA:    PSYCHIC   ANESTHESIA    FOR   TOUCH; 
PSYCHIC    ANOSMIA;    PSYCHIC    BLINDNESS. 

In  beginning  this  record  of  the  lessons  given  at  my 
clinic  I  may  mention  that  this  service  is  here  carried 
on  by  the  visiting  physicians  Avith  the  aid  of  the  junior 
staff.  Notwithstanding  the  small  size  of  the  hospital, 
the  ward  and  oat-services  have  given  the  material  for 
such  activity  of  clinical  study  as  few  larger  hospitals 
can  show. 

The  work  thus  done  includes  Morris  Lewis's  well- 
known  examination  with  me  of  the  Seasonal  Relations 
of  Chorea;  a  like  essay  on  the  Summer  Prevalence 
of  the  Palsies  of  Childhood,  by  Sinkler;  Osier's  work 
on  the  Spastic  Palsies;  Eshner's  excellent  essay  on 
Tremors;  J.  K.  MitchelPs  volume  on  Remote  Con- 
sequences of  ^NTerve  Lesions  ;  Hinsdale  on  Station  in 
Health  and  Disease,  and  many  papers,  by  the  author 
and  others,  too  numerous  for  more  than  allusive  men- 

2 


1 4  NER  VO  US  DISEA  SES. 

tion.  Still  more  valuable  is  it  that  here  have  been 
proved  the  availability  of  the  so-called  rest-treatment 
in  open  wards,  and  the  possibility  of  thus  giving  to 
the  poor  what  is  commonly  believed  to  be  attainable 
only  by  the  richer  classes. 

I  feel  glad  to  say,  indeed,  that  while  the  papers 
named,  and  a  host  of  others,  illustrate  the  careful  scien- 
tific use  made  of  our  wards  and  laboratory,  we  do  not 
forget  that  the  first  object  of  our  wards  is  the  cure  of 
disease/ 

Certain  of  these  lessons,  therefore,  will  not  deal  alone 
with  the  many  singular  cases  which  are  likely  to  come 
before  us,  but  also  with  therapeutic  methods  in  use 
here  before  they  were  thought  possible  in  hospitals, 
or  that,  as  I  think,  are  better  applied  and  better  known 
within  these  walls  than  outside  of  them. 

The  first  case  I  ask  you  to  look  at  to-day  is  from 
Scott  Ward.  Watch  her  as  she  enters.  Her  self-con- 
scious, fixed  facies  will,  or  should,  strike  you.  Xute 
her  ways.  At  one  moment  she  seems  blind ;  at  the 
next,  she  moves  with  swift  ease.  Her  case  is  full  of 
these  oppositions.  I  read  it,  and  all  of  it,  now,  before 
her,  as  she  is  exceedingly  intelligent,  and  will  set  us 
right  if  we  err.  Dr.  Pershing,  of  Denver,  has  greatly 
helped  us  as  to  the  early  history,  and  saw  with  clearness 
of  medical  judgment  into  the  true  nature  of  this  un- 
usually instructive  case,  which,  owing  to  its  changeful 
features,  has  greatly  puzzled  me.  I  have  now  reached 
conclusions  which  carry  my  comprehension  of  it  up  to 
a  point  beyond  which  the  case  itself  does  not  suffici- 
ently yield  clinical  material  for  a  further  advance. 

I  In  the  report  for  1895  is  a  list  of  papers  produced  by  the  statf  and  assist- 
3.nts. 


HYSTERIA.  15 

Case  I. — B.  L.,  a  woman,  aged  forty-two  years,  mar- 
ried, applied  for  treatment  October,  1892,  complaining  of 
blindness. 

Family  history.  Her  mother's  father  was  paralyzed. 
One  of  her  mother's  brothers  had  hydrocephalus,  and  was 
epileptic  and  blind  for  a  year  and  a  half  before  his  death 
from  typhoid  fever  when  twenty-seven  years  old.  Her 
father  died  of  pulmonary  tuberculosis.  One  sister  died  of 
some  spinal  disease,  said  to  have  been  caused  by  a  fall  three 
and  a  half  years  previously. 

Personal  history.  The  patient  has  two  living  healthy 
children  ;  two  others  died.  She  has  had  five  abortions. 
She  does  not  use  alcohol.  There  is  no  evidence  of  syphilis. 
Nor  has  she  had  any  serious  illness  except  typhoid  fever 
at  the  age  of  fourteen  years.  For  many  years  the  woman 
has  been  greatly  troubled  by  family  matters,  and  especially 
in  consequence  of  a  child's  death. 

The  present  disorder  began  in  1887.  Soon  after  a  mis- 
carriage she  found  that  it  was  becoming  difficult  for  her 
to  recognize  large  objects,  while  small  ones  could  be  seen 
easily.  In  reading  she  was  compelled  at  last  to  spell  each 
word,  because  she  could  see  only  one  letter  at  a  time.  She 
was  fitted  with  glasses,  but  no  relief  followed  their  use.  As 
time  passed,  vision  grew  worse.  As  the  form-fields  nar- 
rowed she  recognized  persons,  not  by  their  faces,  but  by 
their  clothing  and  general  bearing.  She  could  see  a  small 
piece  of  silk  or  a  pin  upon  the  floor,  but  could  not  recog- 
nize large  objects. 

During  the  second  year  she  lost,  to  a  great  degree,  the 
power  of  recognizing  colors.  She  could  walk  perfectly  well, 
and  avoided  obstacles.  During  the  third  year  she  could 
still  see  small  objects,  but  could  not  tell  whether  or  not  a 
house  was  completely  built,  or  distinguish  a  man  from  a 
horse.  In  the  fourth  year  she  began  to  strike  against 
objects  in  walking,  and  everything  appeared  dark.     She 


1 6  NEB  VO  US  DISEASES. 

could  distinguish  between  night  and  day,  and  even  between 
a  bright  and  a  dim  light. 

In  December,  1891,  she  was  examined  and  treated  by 
Dr.  Pershing,  who  has  kindly  furnished  me  the  follow- 
ing additional  notes:  "She  is  sent  to  me  as  being  per- 
fectly blind.  Lately  she  has  lost  command  of  words 
and  finds  it  difficult  to  carry  on  a  conversation,  because 
words  do  not  come  to  her  mind,  and  are  not  understood 
when  heard,  though  she  can  readily  repeat  them  after 
another  person.  Recently  something  was  said  about  a 
dust-pan  and  brush.  She  repeated  the  words,  but  had 
no  idea  what  they  meant  until  she  handled  the  objects, 
when  the  idea  came  back.  She  complains  of  inability  to 
perform  the  simplest  arithmetical  operations  (but  this  is 
inconstant),  and  also  to  recognize  by  touch  familiar  objects 
of  dress,  such  as  a  belt.  She  consulted  Dr.  Starr  and  Dr. 
Roosa,  of  Xew  York,  in  November,  1890.  She  could  not 
name  colors  for  Dr.  Roosa,  but  a  few  days  later  sorted 
w^orsteds  correctly  for  Dr.  Charles  H.  Thomas,  of  Phila- 
delj^hia. 

"  Status  proesens.  She  recognizes  the  difference  between 
light  and  darkness.  She  cannot  count  fingers  or  the  win- 
dows in  the  room.  The  pupils  are  equal  and  each  reacts 
to  light  falling  only  on  the  other  eye.  The  ophthalmo- 
scopic appearances  are  normal.  An  interrupted  galvanic 
current  of  one  milliampere  applied  to  either  side  of  either 
eyeball  gives  a  distinct  subjective  flash.  The  examination 
of  the  other  special  senses,  in  all  their  forms,  general  sen- 
sibility, motion,  and  the  reflexes,  shows  nothing  abnormal. 
She  is  not  led,  and  in  going  out  of  a  room  finds  the  door- 
knob without  feeling  for  it,  though  not  always.  She  im- 
proved under  treatment  by  massage,  electricity,  iron, 
quinine,  and  strychnine,  and  moral  means.  Just  before 
leaving  the  hospital  she  told  me  that  she  had  thought  she 
was  totally  blind,  l)ut  she  knew  now  that  she  could  not 


HYSTERIA.  1 7 

possibly  have  been  so,  because  she  was  in  the  habit  of 
doing  many  things  for  which  sight  was  absokitely  neces- 
sary. This  statement  was  volunteered  as  the  result  of  her 
OAvn  reflection.  After  careful  study  of  the  case  I  was  cer- 
tain it  was  hysterical."  (The  accompanying  diagrams 
show  the  fields  of  vision  taken  by  Dr.  Pershing.) 

The  improvement  in  her  condition  that  took  place  while 
in  Dr.  Pershing's  care  soon  disappeared  under  the  stress  of 
family  trouble. 

Present  state  (October,  1892).  The  face,  when  at  rest,  is 
vacant  and  expressionless.  The  Avoman  moves  about  the 
room  with  apparent  ease,  and  rarely  stumbles  against  an 
object.  While  her  gait  is  not  that  of  a  blind  person,  it 
also  is  not  that  of  one  with  normal  vision.  When  any 
object  is  put  before  her  eyes  she  says  she  cannot  tell  what 
it  is.  On  being  told  to  cross  the  room  and  sj^eak  to  a  gen- 
tleman standing  there,  she  goes  in  the  proper  direction,  but 
is  greatly  surprised  to  find,  on  hearing  the  supposed  man 
speak,  that  it  is  a  woman.  When  a  watch  is  given  her  and 
she  is  asked  to  tell  what  it  is  by  touch,  she  fails.  If,  how- 
ever, it  is  put  near  enough  to  her  ear  for  her  to  hear  the 
ticking,  she  names  it  immediately.  She  fails  to  recognize 
a  clothes-brush  by  touch,  but  when  she  hears  me  use  it, 
says  :  "It  is  what  you  brush  clothes  with — a  clothes-brush." 
The  same  is  true  of  a  nail-brush,  except  that  she  calls 
it  a  hair-brush.  She  cannot  at  first  recognize  a  key  by 
touch,  but,  on  being  told  that  it  has  to  do  with  a  door, 
says,  rather  doubtingly,  "It  is  a  door — door-knob,"  and 
then  quickly  corrects  herself,  saying,  "  No,  it  is  a  door- 
key."  She  fails  entirely  to  recognize  a  knife  by  touch. 
On  being  given  a  pencil  she  calls  it  a  penknife,  and  adds, 
"It  is  Avhat  you  write  Avith,"  and  does  not  seem  to  be 
aAA^are  of  her  error.  At  one  examination  she  was  entirely 
unable  to  tell  coins  or  cA^en  to  recognize  that  they  Avere 
metal,  but  the  next  day  she  recognized  a  fiAX-cent  piece 

2^ 


HYSTERIA.  19 

after  considerable  difficalty,  and  then  quickly  told  quar- 
ters, halves,  and  dollars.  She  could  not,  however,  distin- 
guish between  a  one-cent  and  a  five-cent  piece.  A  pen- 
holder, with  pen  attached,  she  calls  a  pen.  A  plate  she 
names  properly,  but  calls  a  tumbler  first  a  plate,  then  a 
bowl,  and  finally  a  tumbler.  A  pin,  a  needle,  a  book,  a 
pair  of  scissors,  and  a  piece  of  paper  she  knows  instantly 
by  touch,  but  sometimes  not  at  all.  She  says  that  a  ball 
put  in  her  hand  is  round,  when  asked  its  shape,  and  recog- 
nizes a  piece  of  cardboard  cut  in  the  form  of  a  circle.  She 
calls  a  triangular  card  three-cornered,  but  all  rectangular 
cards  are  to  her  square.  An  oval  she  sometimes  calls 
square,  sometimes  round.  After  being  told  several  times 
what  an  object  put  in  her  hands  is,  she  remembers  it  and 
answers  correctly  several  days  later. 

The  sense  of  contact  is  perfect.  There  is  no  anaesthesia. 
She  immediately  responds  when  touched,  and  can  tell  the 
point  of  a  pin  from  the  head,  always  answering  properly 
''  dull  "  or  "  sharp."  She  cannot,  however,  localize  sensa- 
tion, so  as  to  name  the  fingers,  but  can  put  a  finger  cor- 
rectly on  the  place  touched.  The  pain-sense  is  normal. 
The  temperature-sense  is  normal. 

If  salt  or  sugar  be  put  upon  the  tongue,  she  names  the 
former  and  says  the  latter  is  sweet  like  candy  or  sugar, 
and  taste  seems  to  be  correct  as  to  even  more  delicate 
flavors.  Given  benzine,  cologne,  alcohol,  and  oil  of  tur- 
pentine to  smell  she  says  she  recognizes  them  as  different, 
but  cannot  name  them.  She  says  they  are  unlike.  She 
can  write  her  initials  and  the  first  part  of  her  surname 
fairly  well,  the  latter  part  being  a  scrawl.  She  cannot, 
however,  write  any  isolated  letters  except  o  and  c.  She 
describes  the  latter  as  o  with  a  piece  cut  out.  If  her  hand 
be  guided  in  making  letters,  she  still  fails  to  recognize 
them.  She  cannot  even  write  the  letters  of  her  name 
unless  she  begins  at  the  beginning. 


20  ^ER  VO  US  DISEASES. 

What  may  be  called  spontaneous  speech — I  mean  the 
speech  of  ordinary  conversation — is  at  the  present  time 
normal,  though  she  claims  that  formerly  she  misused 
words.  For  example,  though  she  may  not  be  able  to 
name  an  object  when  given  to  her,  yet  if  she  wants  it  she 
will  use  the  proper  word  in  asking  for  it.  Notwithstanding 
her  claim  that  she  has  forgotten  how  to  spell,  she  spells 
short  words  correctly.  She  also  solves  simple  arith- 
metical 2:)roblems.  She  is  nervous,  depressed,  and  at  times 
lachrymose. 

Dr.  de  Schweinitz  has  examined  her  eyes  and  reports  as 
follows  :  "  There  is  divergent  squint  in  the  right  eye.  The 
pupils  are  large,  reacting  slowly  to  light ;  the  right  very 
sluggishly.  The  discs  are  grayish-red.  The  veins  are  full ; 
the  arteries  are  small — the  smaller  in  the  right  eye.  There 
is  lack  of  fixation,  but  the  patient  sees  light  in  all  direc- 
tions. The  right  eye  open  (the  left  closed)  perceives  ob- 
jects to  the  left  of  the  median  line  and  sometimes  in  the 
middle,  but  not  to  the  right.  The  left  eye  open  (the  right 
closed)  perceives  objects  to  the  left  and  in  the  median 
line,  but  not  to  the  right.  There  is  partial  right  lateral 
hemianopsia.  Given  cards  to  sort,  she  matches  blue  ones 
correctly,  but  confuses  red  and  green  and  all  others.  It 
was  impossible  to  take  the  color-fields." 

Remarks.  A  few  preparatory  words  may  make 
easier  for  you  my  after-explanations.  AVe  associate  with 
known  objects  their  possession  of  certain  qualities  of 
dimension,  form,  texture,  color,  etc.  These  objects  are 
mentally  classified-  and  labelled — a  pencil,  a  box,  a 
hat,  and  so  on.  AVhen  we  see  or  handle  one  of  these 
objects,  and  find  by  sight  or  touch  that  it  possesses  a 
group  of  qualities,  we  must  determine  on  the  label, 
after  swift  comparison  with  the  collected  complex 
memories  of  things  already  seen  or  handled,  or  both. 


HYSTERIA.  21 

It  will  help  us  to  look  at  this  problem  in  the  most 
simple  form.  When  we  examine  by  sight  or  touch  a 
familiar  object,  a  single  hint,  as  it  were,  may  suffice,  as 
the  tick  which  suggests  a  watch.  If  the  object  be  very 
novel,  the  examination  as  to  the  determinative  proper- 
ties and  their  associations  and  degrees  may  be  long  and 
difficult.  We  store  away  these  acquisitions  for  compari- 
son in  certain  cerebral  centres,  visual  or  tactile,  or  both. 

As  regards  olfaction,  the  questions  the  examinative 
sense,  so  to  speak,  can  ask  and  answer  are  limited. 
Usually,  as  concerns  the  non-pungent  odors,  one  single 
quality  is  perceived,  and  from  it  the  individual  reasons 
by  comparison  Avith  past  memories  of  scents,  and  de- 
clares the  label  lie  is  accustomed  to  assign  to  the  odor 
in  question.  This  is  very  simple,  compared  to  the  com- 
plexity of  the  properties  by  which  visual  and  tactile 
recognitions  are  made. 

In  persons  who  are  ^'  mind-blind/^  as  Muuk  called 
it,  '^  the  thing  put  before  them  is  seen,  but  suggests  no 
corresponding  psychical  idea.'^  Now  what  is  here  meant 
by  being  seen  is  one  of  two  things,  or  both  together. 
The  thing  seen  may  be  present  to  the  man  as  an  image  is 
to  a  mirror,  for  the  mirror  has  no  memory,  and  cannot 
compare  the  present  with  the  past;  or  else  it  is  meant 
that  beside  this  the  object  so  seen  may  present  recognized 
qualities,  but  that  the  patient  has  no  power  to  place 
these  for  comparison  with  those  of  other  periods.  In 
neither  case  can  he  label  the  object  or  say  what  use  it 
has,  although  he  may  occasionally  do  this  latter,  even 
when  he  cannot  name  it.  The  object  may  be  seen,  its 
qualities  compared  with  older  memories,  its  nature  or 
use  be  thus  known,  and  yet  the  power  to  label  it  with 
the  vocal  sign  we  call  a  word  be  lost. 


22  ^ER  VO  US  DISEA  SES. 

These  sets  of  conditions  are  all  seen  in  this  case  at 
times.  Tluis,  I  blindfold  the  woman,  and  offer  to  her 
nose  vinegar,  cologne,  asafoetida,  valerian.  She  says 
they  are  different;  does  not  take  one  for  another.  In 
other  words,  she  does  not  say  all  alike  are  odors  with- 
out difference;  but  a  clear  perception  of  the  single 
quality  so  felt  as  different  in  each  cannot  be  lodged  in 
relation  to  former  knowledge  for  comparison.  Hence 
it  has  no  distinctiveness  and  cannot  be  labelled. 

It  is  interesting  to  study  this  simple  case,  and  then 
that  of  sight.  Here  the  partial  general  blindness  and 
the  added  hemianoptic  imperfection  complicate  mat- 
ters, and  these  conditions  vary  from  day  to  day.  You 
will  remember,  also,  that  all  color-sense  is  dead,  except 
as  to  blue,  and  that  the  form-field  is  much  con- 
tracted. Still,  at  times  she  can  see  the  hands  of  a  watch 
— not,  however,  so  as  to  tell  the  hour.  At  her  best 
moments  she  may  appreciate  qualities  sufficiently  to 
say  that  one  thing  is  larger  than  another,  but  not  so  as 
to  say  that  this  is  round  or  square.  At  these  times  she 
is  able  to  distinguish  one  person  from  another,  but  never 
to  label  them  until  they  speak.  In  her  worse  ocular 
states  she  cannot  distinguish  any  form  of  qualitative 
difference.  You  will  remember  that  Dr.  Pershing  de- 
scribes her  as  having  been  at  one  time  word-deaf,  as 
now  she  is  word-blind. 

This  trouble  is  better  known  and  more  often  seen 
than  the  yet  more  curious  form  of  defect  as  regards 
touch.  Remember  that  she  can  tell  heat,  cold,  touch, 
pain  in  all  degrees.  Occasionally  she  spontaneously 
describes  a  test-object;  more  often  she  does  not,  and 
yet  is  able,  as  the  stated  inquiries  show,  to  answer  cor- 
rectly all  the  queries  competent  to  describe  an  object. 


HYSTERIA.  23 

Very  often  the  final  question,  What  is  it?  she  cannot 
answer;  or  else,  and  rarely,  says  what  it  is  for,  but  not 
its  name.  At  other  times  she  cannot  reply  as  to  the 
qualities  as  told  by  touch  alone,  or  tell  scissors  from  a 
corkscrew,  a  book  from  a  watch;  and  yet  tact  is  per- 
fect. This  corresponds  to  mind-blindness.  She  is 
mind-touchless.  There  is  psychic  anaesthesia  as  to 
touch;  or,  to  be  more  accurate,  either  this  is  true,  or 
else  she  has  lost  the  power  of  mentally  comparing 
new  sensations  with  the  stored  memories  of  those  long 
acquired. 

I  have  not  spoken  of  the  localities  involved  in  this 
triple  loss.  Concerning  these  our  knowledge  is  still  in- 
complete, and  cases  of  hysterical  representation  of  these 
singular  symptoms  are  least  of  all  suitable  to  help  us. 
And  certainly  this  patient  is  an  hysterical  illustration 
of  mental  incapacities  to  use  the  information  won 
through  smell,  sight,  and  touch;  and,  as  I  am  sure  such 
cases  are  very  rare,  I  have  thought  it  worth  while  to 
state  for  you  the  reflections  which  this  one  has  brought 
to  my  mind.  Dr.  Pershing  had  reached  a  like  conclu- 
sion early  in  the  case.  Of  course,  these  cases  all  have 
alexia  and  agraphia.  It  has  been  suggested  that  the 
various  memorial  incapacities,  such  as  the  total  loss  of 
knowledge  of  localities  or  of  individuals,  maybe  limited 
forms  of  mind-blindness, as  if  one  room  in  the  many  man- 
sions of  memory  were  suddenly  walled  up.  These  are, 
I  think,  yet  more  complex  conditions  of  psychic  dis- 
order, and  only  a  part  of  them  may  fairly  be  referred 
to  the  form  of  mental  trouble  which  this  case  exhibits 
in  so  many  varieties.  Finally,  we  need  a  better  term 
than  mind-blind,  and  a  good  Avord  for  the  corresponding 
condition  in  which  touch  and  smell  are  involved. 


24  ^""EB  VO  US  DISEASES. 

It  has  seemed  to  me  that  all  of  these  curious  states  of 
consciousness  as  to  objects  seen  or  felt  may  be  repre- 
sented in  the  changing  psychic  development  of  a  child — 
objects  seen  in  early  life  are  first  represented  as  on  a 
mirror;  later,  their  qualities  are  defined;  and,  lastly, 
they  are  labelled. 

Dr.  Pershing  writes  to  me  of  the  later  history  as 
follows  : 

March  9, 1896.  The  woman  with  mind-blindness  gradu- 
ally grew  worse  after  her  return  from  Philadelphia.  While 
walking  one  evening  with  her  mother,  who  is  very  deaf, 
they  were  both  struck  by  a  cable  car,  but  apparently  not 
seriously  injured.  When  I  saw  Mrs.  S.  a  few  weeks  after 
this  accident  she  could  not  talk  rationally  on  any  subject, 
but  kept  talking  in  a  senseless,  bewildered  way,  the  words 
being  distinctly  uttered  with  occasionally  a  pause,  as  though 
the  word  did  not  appear  in  memory.  "  Water-closet"  was 
repeated  with  especial  frequency,  without  any  logical  or 
grammatical  connection  with  other  words.  The  intellect 
was  evidently  much  impaired,  and  she  had  to  be  constantly 
attended.  The  pupils  Avere  widely  dilated,  and  one  eye, 
the  left,  I  think,  turned  out.  The  pupils  did  not  contract 
in  a  bright  hght.  The  ophthalmoscope  showed  nothing 
abnormal. 

In  the  summer  of  1894  she  came  as  an  insane  patient 
to  the  County  Hospital,  in  my  service  ;  but  I  was  away  at 
the  time,  and  Dr.  Eskridge,  who  had  charge  of  my  patients, 
had  her  taken  to  St.  Luke's  as  a  private  patient.  That 
ended  my  connection  with  the  case,  but  I  know  that  she 
remained  demented  and  was  at  times  noisy.  She  died  in 
the  autumn  of  1894. 


CHAPTEE    II. 

RECURRENT  MELANCHOLIA:  SEASONAL  MELANCHO- 
LIA; MELANCHOLIA  ARISING  OUT  OF  MENSTRUA- 
TION; INTER-MENSTRUAL  MELANCHOLIA;  MELAN- 
CHOLIA ARISING  OUT  OF  DREAMS  OR  ORIGINATING 
IN  THE  POST-DORMITIUM;  MELANCHOLIA  DURING 
DIGESTION. 

I  HAVE  long  had  in  mind  to  speak  to  you  of  certain 
forms  of  the  mental  disorder  we  call  melancholia,  and 
of  which  at  this  clinic  we  see  so  many  examples.  It 
sometimes  offers  for  our  consideration  peculiarities  of 
origin  which  have  not  received  the  attention  they  should 
have  had. 

As  usual  in  these  lessons,  which  are  informal,  and  not 
meant  to  cover  the  whole  medical  history  of  the  subject, 
I  shall  limit  myself  to  speak  of  so  much  of  the  matter 
in  hand  as  shall  appear  to  me  desirable  to  dwell  upon. 
Assuredly,  the  treatment  of  mental  disorders  is  one  of 
the  least  satisfactory  of  the  varied  problems  with  which 
we  have  to  deal.  About  nothing  do  we  knoAV  less  than 
of  the  true  pathology  and  ultimate  cause  of  the  dis- 
orders which  we  group  under  the  name  of  insanity. 
Indeed,  we  are  as  yet  uncertain  as  to  where  Avithin 
the  skull  is  the  nerve-matter  with  which  we  think  or 
imagine.  The  abruptly  occurring  accidents  to,  or 
diseases  of,  joint,  muscle,  or  nerve,  we  can  measurably 
comprehend;  but  when  we  come  to  deal  with  disorders 
of  the  brain  we  are  at  once  face  to  face  with  certain 
unanswered  questions. 


26  ^"^'ER  VO  US  DISEASES. 

While  most  disorders  of  the  mind  are  apt  to  origin- 
ate gradually,  and  often  take  a  long  while  to  become 
formidable,  at  other  times  these  troubles  spring  up  sud- 
denly; and  this  is  more  frequently  the  case  with  all  the 
forms  of  methodically  recurrent  disease  of  the  mind. 
I  do  not  mean  to  say  that  sudden  outbursts  of  mania 
or  melancholia,  such  as,  according  to  the  German  writers 
and  others,  are  more  prone  to  occur  in  recurrent  exam- 
ples of  these  disorders,  are  very  common  ;  but  only  that 
they  are  to  be  met  with,  and  that  when  we  do  see  them 
they  still  further  emphasize  the  difficulty  of  explaining 
that  which  happens  within  the  brain  at  the  time  of 
occurrence  of  such  outbreaks.  A  strong  emotion,  a 
dream  as  I  shall  show,  or  some  as  inexplicable  cause, 
may  occasion  forms  of  temporary  or  lasting  mental  dis- 
order, for  which  we  have  as  yet  no  reasonable  explana- 
tion. The  largeness  of  the  psychical  and  the  smallness 
of  the  observable  co-attendant  pathological  physical 
conditions  never  cease  to  amaze  the  thoughtful. 

Usually  these  and  all  forms  of  such  morbid  psychoses 
get  well  slowly;  but  sometimes  recovery  even  in  chronic 
cases  is  as  abrupt  as  may  have  been  the  origin,  and 
then  one  asks  in  vain  what  could  have  been  the  nature 
of  the  morbid  factors  which,  acting  suddenly  or  slowly, 
are  efficient  for  years,  and  perhaps  cease  to  have  dis- 
ordering competency  in  a  night  or  a  day.  Such  cases 
are,  indeed,  rare,  as  I  have  said;  but  they  do  exist,  and 
may  be  met  with  at  times  in  some  of  the  recurrent 
melancholias  to  which  presently  I  desire  more  especially 
to  call  attention. 

The  individuals  who  constitute  mankind  have  what 
one  might  call  a  par  of  cheerfulness.  It  varies,  of  course; 
is  subject  to  the  vici.<situdes  called  moods,  and  is  low 


MELANCHOLIA.  27 

or  high  according  to  the  nature  of  that  lifelong  mood 
which  we  describe  as  temperament.  This  climate  of 
the  mind  may  be  such  in  certain  persons  as  to  defy  all 
forms  of  misfortune,  and  to  preserve  some  sense  of  hap- 
piness in  the  face  of  poverty,  disease,  disaster,  and  even 
death  itself.  There  are  others  who  so  precisely  reverse 
this  happy  constitution  of  mind  as  to  need  from  me  no 
further  description.  It  is  quite  sure  that  either  mental 
attitude  can  be  combated  or  fostered.  The  wisdom 
which  cultivates  cheerfulness  until  it  becomes  habitual 
is  of  the  mental  hygiene  of  habit. 

The  atmosphere  of  cheerfulness  is  often  a  family  gift, 
an  inheritance;  you  feel  its  presence  with  some  people, 
in  some  houses.  Other  men  or  women  carry  with  them 
a  certain  indefinable  air  of  defeat,  discouragement,  and 
gloom.  Such  persons  and  such  families  are  not,  of 
necessity,  liable  to  that  morbid  condition  we  call  melan- 
cholia; for,  as  Cloustou  has  very  Avell  insisted,  mere 
melancholy  and  melancholia  are  two  quite  different 
things.  The  disorder  may  alight  on  the  most  cheerful. 
There  are,  however,  persons,  and  rarely  whole  families, 
who,  living  continually  below  the  normal  level  of  that 
happiness  which  comes  of  natural  cheerfulness,  are  of 
those  who  are  foredoomed  to  have,  at  irregular  inter- 
vals, attacks  of  melancholia,  and  to  be  always  nearer  to 
suicidal  temptations  than  the  rest  of  mankind.  Such 
races  should  not  be  perpetuated;  but  society  has  not 
seen  fit  to  protect  its  future,  and  I  have  only  once  known 
an  instance  of  such  a  family  having  resolved,  by  avoid- 
ing marriage,  to  end  what  had  been  ancestral  genera- 
tions of  disaster. 

I  was  permitted  years  ago  to  print  the  record  of  one 
of  these  unhappy  races,  now,    I   believe,  extinct.     I 


28  ^'ER  VO  US  DISEASES. 

never  used  the  privilege,  and  have  withio  a  few  years 
mislaid  the  memoranda  furnished  me  by  one  of  its 
number.  I  retain  a  distinct  remembrance  of  eoough 
of  this  history  to  serve  my  present  purpose.  The  people 
concerned  were  none  of  them  remarkable  for  mental  gifts 
above  the  average  of  man.  I  knew  four  of  them; 
three  of  these  "were  sallow  and  had  dark  skins  and 
black  hair;  they  described  their  parents,  who  were 
cousins,  as  having  been  of  like  appearance.  All  of 
them  who  were  known  to  me  were  physically  sluggish, 
and  more  or  less  lacking  in  e very-day  gaiety;  but  two 
at  least  were  humorous  at  times,  and  apparently  capable 
of  amusing  others  more  than  themselves. 

In  about  one  hundred  and  fifty  years,  in  the  various 
lines  of  descent  known  to  them,  they  had  record  of 
eleven  suicides,  nine  having  been  males  and  two 
females;  there  were  several  epileptics,  much  drunken- 
ness of  later  years,  and  in  every  generation  cases 
of  insanity — sometimes  acute  mania,  more  usually 
melancholia.^  AVhen,  quite  thirty  years  ago,  the 
family  became  reduced  to  three  single  women  and 
one  man,  an  agreement  not  to  marry  was  reached, 
and  was,  I  believe,  scrupulously  kept.  I  saw  two 
cases  among  these  people.  Both  were  in  women 
between  thirty  and  forty  years  of  age;  both  were  2:)ure 
melancholias  without  delusions,  except  as  to  religious 
matters;  both  were  piteous  examples  of  the  mental  suf- 
fering which  this  disorder  may  inflict. 

I  have  occasionally  known,  in  a  long  experience,  per- 
sons who  all  through  life  were  subject  to  what  are  pop- 
ularly called  the  "  blues,''  to  moods  of  depression  and 

^  With  all  of  this  sad  history  it  is  notable  that  there  was  no  instance  of 
any  form  of  crime. 


MELANCHOLIA.  29 

the  like,  but  who  throughout  escaped  true  melancholia. 
There  are,  as  I  have  also  said,  exceptions  to  this  happy 
rule,  and  the  family  whose  history  I  allude  to  were 
for  the  most  part  sad-minded  people.  The  only  one  of 
them  who  entirely  escaped  attacks  of  insanity  was  a 
quite  cheerful  woman,  who  had  the  fair  hair  and  blue 
eyes  of  a  grandmother  of  another  race. 

It  is  a  question  how  far  the  individual  of  breeds  like 
this  one  may  be  influentially  hurt  by  knowdedge  of  such 
a  series  of  mental  disasters  among  near  relatives.  I 
am  sure  that  most  persons  so  situated  would  be  apt  to 
feel  a  dread  of  the  coming  of  their  family  peril;  but  if 
this  natural  apprehension  be  capable,  in  turn,  of  adding 
a  serious  contributive  factor  to  hereditary  tendencies,  I 
do  not  fully  know. 

I  have  been  many  times  consulted  as  to  the  propriety 
of  marriage  in  cases  of  those  who  have  been  insane,  or 
who  are  come  of  those  rare  families  in  which  neuroses 
have  been  so  frequent  as  to  make  reasonable  a  doubt  as  to 
the  right  to  doom  oifspring  to  the  probabilities  of  mental 
disorders.  There  are  extreme  cases  in  which  decisions 
are  easy.  It  is  the  other  groups  which  are  hard  to  deal 
with;  I  mean  those  in  which  the  record  is  not  so  terribly 
disastrous  as  in  that  which  I  have  selected  as  a  typical 
instance.  All  sorts  of  questions  are  involved:  emo- 
tional, social,  economic.  The  quality  of  the  previous 
insanities  is  to  be  considered,  and  the  nature  of  the 
causes  which  seem  to  influence  the  outbreaks.  If  it 
be  a  varied  family  history  with  which  we  have  to  deal, 
the  matter  becomes  difficult,  and  often  anyone,  except 
a  modern  psychological  novelist,  would,  and  perhaps 
sometimes  should,  with  reason,  refuse  to  give  positive 
advice. 

3* 


30  ^ER  VO  US  DISEASES. 

I  should  like,  did  my  time  permit,  to  study  with  you 
here  this  interesting  problem.  I  should  like  to  see  it 
fully  discussed  by  some  alienist  of  large  experience, 
capable  of  dealing  with  it  from  all  points  of  view. 

Closely  connected  with  this  matter  is  the  advice  to 
be  given  as  to  the  training,  and  the  moral  and  physical 
education  of  the  children  of  persons  in  whose  families 
there  is  or  has  been  such  frequency  of  mental  disorder 
as  to  make  it  wise  to  consider  these  risks  while  we  are 
still  able  to  handle  the  plastic  material  of  childhood. 
Here  again  is  a  problem,  not  unanswerable,  and  need- 
ing to  be  largely  considered. 

I  pass  from  these  hiuts  for  the  reflective,  to  ask  atten- 
tion to  some  of  the  melancholias  which,  as  to  origin, 
seem  to  be  conditionally  related  to  season,  function, 
and  other  more  obscure  factors.  In  treating  of  this 
subject  I  shall  for  the  most  part  limit  myself  to  cases 
of  which  I  have  had  personal  knowledge,  or  which, 
having  been  obtained  from  my  friends,  have  not  been 
hitherto  put  in  print. 

Recurrent  melancholia  is,  of  course,  at  times  only 
a  part  of  the  cycle  of  a  form  of  circular  insanity. 
I  have  endeavored  to  exclude  all  such  examples. 
There  is,  however,  I  am  sure,  a  form  of  very  mild 
circular  insanity  to  which  sufficient  attention  has  not 
been  given.  In  this  we  hav^e  melancholias  of  ordinary 
or  extraordinary  type,  followed  by  periods  of  greater  or 
less  duration,  during  wliich  the  person  is  neither  mani- 
acal nor  subject  to  dehisions,  as  in  the  more  typical 
circular  insanities.  In  these,  to  which  I  now  call  atten- 
tion, the  interval  between  tw^o  attacks  of  melancholia 
is  merely  remarkable  for  the  excessive  gaiety  of  the 
patient.     It  is  often  sufficient  to  attract  attention  as 


MELANCHOLIA.  31 

unusual  aud  beyond  what  had  been  observable  in  the 
same  individual  during  a  period  of  perfectly  normal 
life. 

The  recurrent  melancholias  I  have  seen  and  desire 
to  discuss  were  productively  conditioned  on  season,  time 
of  day,  function,  such  as  menstruation  or  inter-menstrual 
periods.  Then,  again,  there  is  melancholia  distinctly 
related  to  the  meal-time,  or,  rather,  to  the  digestive 
period.  Finally,  there  is  the  melancholia  which  is  the 
strange  temporary  outcome  of  dreams,  or  is  related  to 
the  post-dormitium.  I  have  elsewhere  written  of  tlie 
psychoses,  and  especially  of  the  melancholias  and  manias, 
due  to  drugs,  such  as  bromides,  trional,  cocaine,  or 
hemp.^ 

It  is  familiar  knowledge  that  melancholia  is  apt  to 
recur  in  the  person  of  one  who  has  been  once  attacked. 
These  returns  may  be  after  a  year  or  less,  or  after  many 
years.  Too  often  where  the  interval  is  brief  the  patient 
has  never  been  quite  restored  to  the  full  normal  of  cheer- 
fulness. The  recovery,  too  easily  assumed,  is  only  a 
lessened  state  of  depression,  and  soon  again,  the  curve 
of  melancholia  rising,  the  patient  is  said  to  have  a 
second  attack.  This  truth  as  to  many  of  the  melan- 
cholias which  return  at  irregular  and  short  intervals 
has  been  clearly  recognized  by  many  of  our  own  alien- 
ists. It  is  not  of  this  type  of  irregular  recurrence  that 
I  desire  now  to  speak. 

The  melancholias  which  recur  frequently  may  do  so 
at  certain  times  of  the  year,  and  may  continue  so  to 
return  year  after  year.  These  cases  I  may  be  allowed 
to  call  recurrent  seasonal  melancholias.     Some  deter- 

1  Proceedings  of  the  Association  of  Physicians  and  Pathologists,  1896. 


32  ^'ER  VO  US  DISEASES. 

mining  connection  with  the  season  or  its  phenomena 
seems  to  be  efficient  in  evolving  an  annual  attack.  The 
time  of  onset  may  vary  within  a  month  or  two.  Usually 
it  is  in  the  spring  or  early  summer,  and  so  much  more 
common  is  this  than  attacks  in  winter,  that  it  has  made 
me  eager  to  know  how"  far  season  is  influential  in  setting 
the  date  of  such  outbreaks  as  are  primary  or  recur  at 
longer  intervals. 

Regularly  recurrent  melancholias  may  be  of  any  of 
the  several  species  which  are  included  in  what  I  may 
call  the  genus  melancholia.  The  termination  may  be 
finally  as  various  as  in  the  ordinary  single  or  irregularly 
recurrent  examples. 

Well-marked  seasonal  melancholia  is  a  rare  disorder. 
The  case  which  I  shall  first  relate  is  an  admirable  illus- 
tration of  the  malady.  I  owe  it  to  the  kindness  of  the 
attending  physician,  Dr.  M.  V.  Ball,  and  its  complete- 
ness to  the  very  full  notes  made  by  my  assistant.  Dr. 
Rhein: 

Case  II. — The  patient,  D.  B.,  is  a  Russian  by  birth,  aged 
thirty  years,  married,  and  has  borne  two  children.  Her 
business  is  that  of  a  midwife.  The  beginning  of  her  dis- 
ease dates  sixteen  years  ago.  It  consists  in  a  periodical 
recurrence  of  a  profound  state  of  melancholia.  In  her 
family  history  there  is  strong  evidence  of  predisposition  to 
insanity.  Her  mother  suffered  from  melancholia  during  a 
part  of  her  life,  a  sister  killed  herself  while  mentally  de- 
pressed, a  second  sister  is  extremely  nervous  and  hysterical, 
and  two  maternal  cousins  are  afilicted  with  melancholia. 

The  patient's  health  prior  to  the  onset  of  the  present 
affliction  was  extraordinarily  good.  She  possessed  an  un- 
usually acute  mind,  and  had  a  most  retentive  memory, 
easily  acquiring  at  an  early  age  command  of  three  lan- 
guages besides  her  own. 


MELANCHOLIA.  33 

The  first  symptoms  of  her  malady  appeared  shortly  after 
her  first  menstrual  period,  at  fourteen  years.  There  was 
only  a  mild  mental  depression  at  this  time,  which  lasted 
four  weeks,  and  from  which  she  recovered  entirely.  In  a 
year's  time  she  experienced  a  return  of  the  same  condition, 
which  lasted  again  four  weeks.  A  third  attack  was  in- 
duced by  a  serious  cause  of  worry  eighteen  months  later. 
ilbout  this  time  her  memory  began  to  be  rather  less  per- 
fect, and  she  observed  some  defect  in  her  mental  powers. 
Her  first  pregnancy  was  the  occasion  of  a  fourth  slight 
return  of  mental  depression,  quite  mild  in  character  and 
lacking  entirely  delusional  or  suicidal  tendencies. 

The  first  of  the  regular  series  was  induced  by  the  death 
of  her  child.  The  attack  began  in  March  and  lasted  until 
September.  Her  symptoms  were  then  precisely  those 
which  I  shall  presently  describe.  Since  that  time,  sixteen 
years  ago,  with  persistent  regularity  as  the  month  of  March 
approaches,  she  falls  into  a  state  of  melancholia  from  Avhich 
hitherto  there  has  been  no  escape.  The  symptoms  of  the 
several  attacks  vary  but  slightly ;  her  accustomed  attitude 
is  then  highly  characteristic.  With  hands  clasped  before 
her,  her  eyes  fixed  in  an  upward  direction,  she  remains 
seated  for  hours,  refusing  to  converse,  declining  to  eat, 
and  frequently  weeping.  The  recital  of  her  mental  con- 
dition during  an  attack,  while  most  pathetic,  is  of  unusual 
interest.  There  are  constantly  floating  through  her  mind, 
she  says,  the  most  depressing  thoughts.  Her  condition 
renders  her  a  burden  to  those  about  her ;  she  is  unable 
to  support  herself ;  her  capacity  for  work  is  gone ;  she  is 
unable  to  think  correctly,  to  act  properly,  so  that  she  con- 
siders that,  altogether,  it  would  be  infinitely  more  pleasant 
to  end  all  her  troubles  by  suicide.  This  idea  is  continually 
uppermost.  She  craves  death  and  is  constantly  discussing 
with  herself  plans  to  effect  it.  For  the  sake  of  those  about 
her  she  is  dissuaded  from  killing  herself  while  in  the  house ; 


34  ^ER  VO  US  DISEASES. 

but  to  go  out  of  doors  is  quite  imiiossible ;  no  will-power 
exists  to  prompt  such  a  move.  She  thinks,  if  once  out  of 
doors,  there  would  be  no  barrier  to  the  consummation  of 
her  desire.  This  lack  of  will  induces  within  her  an  intense 
hatred  of  herself,  as  she  says,  "  like  as  no  one  has  ever 
hated  before."  The  mental  anguish  is  so  great  that  bodily 
pain  is  not  felt  if  it  chances  to  occur.  She  has  fre(|ueutly 
attempted  suicide  by  exposing  herself  to  cold  night-air 
with  perhaps  only  a  single  garment.  Thus  death,  she 
thinks,  could  be  achieved  without  inflicting  on  her  rela- 
tives the  ignominy  of  suicide.  She  has  unsuccessfully  at- 
tempted suicide  several  times  by  swallowing  poison.  In 
several  instances  the  attack  has  been  precipitated  by  men- 
tal shocks,  but  more  frequently  there  has  been  no  such 
exciting  cause.  Emotion  or  disaster  at  other  seasons  will 
not  bring  it  on.  During  the  intervals  she  is  happy,  in- 
dustrious, and  capable  ;  said  to  be  in  a  really  normal  state. 
For  a  short  time  in  a  day,  now  and  then,  there  may  be 
some  trivial  depression,  which  she  has  not  the  slightest 
difficulty  in  shaking  off.  When  the  month  of  March 
arrives  she  is  entirely  povrerless  to  rise  above  these  de- 
pressed feelings.  She  becomes  most  apprehensive  of  a 
return,  the  anticipation  of  which  seems  to  lower  her 
resistance. 

There  have  been  always  intense  headaches  at  these  and 
of  late  at  other  times,  which  no  medicine  has  permanently 
helped.  Krafft-Ebing  partially  relieved  her  pain  for  six 
months  by  hypnotizing  her  every  three  days.  He  was 
never  successful  in  inducing  a  very  profound  state  of 
hypnotism.  At  my  request,  Dr.  IJhein  brought  about  this 
condition  and  made  her  quite  completely  insensible,  pro- 
ducing the  highest  degree  of  hypnotism,  during  which 
suggestions  as  to  relief  of  headache  were  made  with  con- 
siderable success. 

An  examination  of  her  physical  condition  in  health  is 


MELANCHOLIA.  35 

as  follows  :  Her  station  is  good  ;  the  knee-jerks  are  slightly 
increased  ;  there  is  no  clonus.  The  strength  of  the  muscles 
in  general  is  normal.  There  is  no  change  in  sensation  any- 
where. The  tongue  is  coated,  the  digestion  is  fairly  good  ; 
bowels  irregular  during  the  attacks,  but  regular  at  other 
times.  The  heart  and  lungs  and  uterine  functions  are 
normal.  The  urine  shows,  but  only  at  times,  free  uric  acid, 
and  is  in  other  respects  natural.  There  exists  a  slight  error 
of  refraction  in  the  eyes,  but  no  change  in  the  fundus  and 
none  in  the  form-  or  color-fields. 

The  attack,  as  I  have  said,  comes  on  in  March,  and 
usually  she  may  expect  it  about  March  1st.  It  lasts  until 
August,  and  goes  away  somewhat  slowly,  becoming  now 
better,  .now  worse,  until  it  disappears.  The  early  attacks 
came  on  abruptly,  in  a  single  day,  and  left  in  the  same 
manner.  When  they  are  coming  on  she  has  anorexia, 
loss  of  vigor,  and  her  sense  of  duty  and  her  will-power 
are  soon  in  abeyance.  No  efforts  seem  to  have  been  made, 
by  any  radical  treatment,  to  anticipate  the  coming  on  of 
her  trouble.  I  hope,  during  the  ensuing  spring,  to  make 
some  effort  to  relieve  her.  My  belief  that  there  was  an 
hysterical  basis  for  her  melancholia  has  been  confirmed 
by  an  interesting  incident : 

On  January  20,  1897,  this  patient  was  insulted  in  the 
street  at  night  and  pursued  by  a  drunken  man.  The  next 
day,  on  awakening,  she  had  complete  loss  of  power  in  the 
legs  and  insensibility  in  all  forms  below  the  knee.  Dr. 
Rhein  hypnotized  her  and  she  was  at  once  able  to  stand 
and  move  freely  when  ordered.  Two  days  later,  at  my 
clinic,  she  was  again  hypnotized  and  walked  still  better. 
This  treatment  will  be  continued,  and  under  it  no  doubt 
the  paretic  state  will  disappear.  As  she  will  now  remain 
iij  the  wards,  I  hope  by  this  and  other  means  to  ward  off 
the  annual  attack  of  melancholia.  The  ease  with  which 
the  hysterical  paraplegia  came  on  points  to  the  possibility 


36  ^ER  VO  US  DISEASES. 

of  the  recurring  mental  disease  having  been  hysterical. 
It  does  certainly  offer  also  in  its  history  some  suggestive 
facts  corroborative  of  this  belief. 

In  the  large  experience  of  my  service,  Drs.  J.  K.  Mitchell 
and  Dr.  de  Schweinitz  have  found,  as  I  have  before  stated, 
very  few  cases  of  such  changes  of  the  color-  and  form-fields 
as  seem  to  be  common  in  France  in  hysterical  palsies.  For- 
tunately, Mrs.  B.'s  eye-grounds  were  studied  with  care  some 
time  ago  and  found  normal.  Just  now^  the  color-fields  are 
reversed,  and  this  is  the  first  time  I  have  met  with  this 
symptom  in  hysterical  paraplegia. 

Case  III. — I  saw  lately  a  woman,  aged  thirty-nine 
years,  of  a  family  in  which  the  mother  had  had  melan- 
cholia. This  lady,  in  November,  1888,  after  some  trivial 
worries,  became  melancholic.  The  attack  lasted  a  month. 
In  May,  1892,  after  childbirth,  the  attack  recurred  and 
lasted  until  the  next  February.  Since  then  she  has  had 
mild  melancholia  beginning  every  August  and  getting  well 
toward  the  close  of  January.  In  the  intervals  she  is  de- 
scribed as  happy  and  sometimes  as  too  hilarious ;  but  this 
she  denies,  and  declares  that  she  is  in  a  perfectly  natural 
condition.  The  melancholia  in  this  case  is  of  the  simplest 
type,  and  without  delusions. 

Case  IV. — Another  example  of  melancholia,  confined 
to  the  months  of  April,  May,  and  June,  was,  for  the  cer- 
tainty of  its  return,  unusually  interesting.  R.  W.,  aged 
forty  years,  naval  officer,  unmarried,  of  good  habits,  came 
of  a  family  well  known  to  me  as  healthy  and  of  unusual 
ability.  At  the  age  of  thirty -four  years  he  was  perilously 
ill  in  the  spring  with  coast  fever,  while  on  the  shores  of 
Africa.  He  recovered  very  slowly,  but  was  never  again 
as  vigorous  as  before.  The  next  spring,  early  in  April, 
he  had  a  sudden  and  seemingly  causeless  melancholia,  with 
suicidal  impulses,  but  without  confessed  delusions.  All  the 
previous  winter  he  had  been  weak  and  dyspeptic,  with  an 


MELANCHOLIA.  37 

irritable  bladder  and  immense  deposits  of  oxalates,  but 
rarely  any  free  uric  acid.  The  melancholia  lasted  until 
July,  and  this  attack  repeated  itself,  with  systematic  per- 
sistency, every  year,  seven  successive  times.  Meantime  he 
acquired  improved  health,  lost  his  oxalates  and  bladder- 
trouble,  and  was  able  to  eat  without  indigestion  if  he 
were  reasonably  careful ;  nor  did  the  condition  of  the  urine 
to  which  I  have  alluded  return  again  during  the  successive 
attacks  of  melancholia.  His  urine  was  at  these  times  sin- 
gularly free  from  the  deposits  so  commonly  seen  in  these 
cases,  and  in  fact  in  many  forms  of  insanity.  Still,  whether 
at  home  or  at  sea,  in  city  or  country,  his  attacks  returned 
every  year.  After  eight  of  these  onsets  he  married,  and 
thenceforward  was  not  again  the  victim  of  melancholia  up 
to  his  death,  from  pneumonia,  at  the  age  of  fifty-one  years. 

Here,  again,  there  was  some  determining  element  in 
the  spring,  but  beyond  this  evident  conclusion  I  am 
unable  to  go. 

I  owe  the  two  cases  which  follow  to  the  kindness  of 
Dr.  Allen  Starr: 

Case  V. — Mrs.  L.  N.,  Kansas,  born  in  1857.  Father 
was  healthy.  Mother  was  a  nervous  invalid,  and  she  has 
been  nervous  from  the  time  she  was  sixteen.  She  has  two 
sisters  who  are  neurotic  and  one  brother  who  is  peculiar 
but  has  never  been  insane.  One  aunt  on  the  mother's 
side  is  said  to  be  erratic.  The  patient's  first  attack  of 
depression  occurred  in  1885,  beginning  in  February,  and 
was  associated  with  the  sudden  cessation  of  menstruation. 
She  became  discontented,  restless,  moody,  and  depressed 
in  spirits ;  was  wilful  and  irritable,  so  that  it  was  impos- 
sible for  her  to  do  housekeeping  or  manage  her  family. 
Her  condition  during  the  first  attack  was  diagnosticated 
by  Dr.  Barstow,  of  Sanford  Hall,  Flushing,  as  melancholia. 
The  attack  lasted  until  July  1st,  when  it  passed  off  sud- 


38  NERVOUS  DISEASES. 

denly  with  a  recurrence  of  menstruation.  She  had  similar 
attacks  every  spring,  the  exact  dates  of  which  are  not 
known,  until  1891.  In  1891  her  attack  began  on  March 
17th  and  lasted  until  September,  the  condition  of  depres- 
sion being  attended  with  suicidal  tendencies,  so  that  she 
had  to  be  carefully  watched  during  the  summer  of  1891. 
I  first  saw  her  in  November,  1891,  and  had  the  charge  of 
her  until  the  following  March,  during  which  time  she  suf- 
fered from  anaemia  and  asthma,  but  was  normal  mentally. 
On  March  30th,  after  an  attack  of  tonsillitis,  her  entire 
manner  and  character  suddenly  changed.  She  became 
excited,  unduly  talkative,  restless  and  irritable,  very  unlike 
herself  in  appearance,  manner,  and  actions  ;  and  this  period 
of  excitement  and  restlessness  lasted  for  ten  days  and  then 
suddenly  changed  into  a  condition  of  deep  melancholia,  in 
which  she  dreaded  seeing  anyone,  w^as  despondent,  cried, 
was  slow  in  her  mental  action,  could  not  concentrate  her 
attention  or  undertake  any  work  for  the  management  of 
her  house ;  disliked  to  see  her  children,  was  afraid  she 
would  do  them  harm,  evidently  had  suicidal  tendencies 
though  she  attempted  to  conceal  them ;  slept  badly,  lost 
weight  rapidly,  became  anaemic,  constipated,  and  suspicious. 
She  remained  in  this  condition  until  August  10th,  when 
with  the  recurrence  of  her  menstruation,  which  had  ceased 
from  March  30th,  she  became  apjiarently  suddenly  well. 

She  had  a  similar  attack  during  the  spring  or  summer 
of  1893,  1894,  1895,  and  1896,  each  attack  beginning  with 
a  period  of  excitement  lasting  two  weeks,  followed  by  a 
period  of  depression  lasting  several  months.  The  attack 
in  1894  began  in  April  and  lasted  until  September.  It 
was  not  benefited  by  a  trip  to  Europe.  The  attack  in 
1895  began  in  May  and  lasted  until  September  22d.  The 
attack  in  1895  lasted  from  April  until  August.  I  may 
add  that  this  lady  had  frequently  an  excess  of  uric  acid 
both  in  and  out  of  her  attacks.  There  were  in  this  case 
eleven  consecutive  attacks  of  melancholia. 


MELANCHOLIA.  39 

Case  VI. — T.  K.,  male,  born  in  Massachusetts  in  1868. 
Family  history  bad.  Cases  of  insanity  on  both  father's 
and  mother's  side.  One  aunt  at  present  in  an  asykim  with 
paranoia.  He  was  born  two  weeks  before  time  and  weighed 
only  five  pounds,  but  appeared  to  be  well  until  his  fifteenth 
year,  when,  in  the  spring,  it  was  noticed  he  was  acting  in 
an  unnatural  manner.  He  wished  to  be  alone ;  he  could 
not  fix  his  attention  upon  study ;  he  became  morbid  in 
various  ways  and  much  depressed.  Such  attacks  have  re- 
curred every  year  since  that  time ;  that  is,  from  the  year 
1883.  In  1888  he  began  to  study  medicine,  and  in  March, 
1889,  first  came  under  my  observation  with  the  previous 
history.  Examination  showed  a  large,  muscular  man,  six 
feet  high,  and  well  developed  physically,  with  a  very 
small  head  and  a  degenerate  type  of  asymmetrical  face, 
badly  formed  ears,  and  high  palate.  Physical  examination 
of  internal  organs  negative ;  heart  rapid,  95,  but  no  mur- 
murs. Good  digestion  ;  no  anaemia  ;  urine  normal.  Men- 
tal condition  of  depression.  It  is  difficult  to  get  him  to 
talk  ;  he  remains  quiet  for  hours ;  refuses  to  see  anyone ; 
prefers  to  stay  at  home,  and  will  not  see  friends  or  occupy 
himself,  excepting  occasionally  with  outdoor  Avork  in  the 
garden.  He  constantly  reproaches  himself  with  various 
imaginary  evils,  and  everything  that  he  has  done  seems 
to  him  to  be  just  the  wrong  thing,  and  he  says  if  he 
had  not  done  this  or  that  he  would  be  all  right.  This 
condition  persisted  from  March  until  July,  when  it  gradu- 
ally passed  off,  and  he  was  well  during  the  summer.  A 
recurrence  took  place  in  October,  1890,  when  I  saw  him 
again  in  the  same  depressed  condition,  confused  in  his 
mind,  unable  to  read  or  study,  moody  and  dull.  His 
reaction-times  to  sight  and  hearing  were  carefully  tested, 
and  found  to  be  increased  in  duration.  This  condition 
lasted  until  December  23d,  when  it  passed  off  suddenly. 
In  September,  1891,  he  had  a  recurrence  of  the  depres- 


40  NERVOUS  niSEASES.  - 

sion,  which  lasted  until  December  29th.  During  this 
time  he  was  melancholy,  unable  to  concentrate  his  mind 
on  any  work,  talked  slowly,  but  had  no  active  delusions. 
He  spent  this  j)eriod  in  the  Adirondacks,  and  was  out  of 
doors  most  of  the  time.  Recovered  suddenly ;  as  he  ex- 
pressed it,  "came  out  from  under  the  cloud."  I  did  not 
see  him  again  until  December  26,  1894,  when  he  Avas  again 
in  a  state  of  depression,  and  said  that  he  had  had  attacks 
lasting  from  September  until  December  each  year  in  the 
preceding  three  years.  When  I  saw  him  he  was  in  a  state 
of  deep  melancholia.  December  1,  1896,  his  father  re- 
ported to  me  that  he  recovered  from  the  attack  in  1894 
during  the  middle  of  January,  but  that  he  had  an  attack 
from  September  to  December,  1895,  and  that  now  (Decem- 
ber 1,  1896)  he  is  in  an  attack  which  began  in  July. 

This  man  has  therefore  had  yearly  attacks  of  melancholia 
from  1883  to  1896  without  any  exception,  lasting  variably 
from  three  to  six  months. 

The  urine  was  examined  very  many  times  and  with  care. 
It  was  not  found  that  the  urea,  uric  acid,  whole  quantity 
of  fluid,  or  total  of  contents  had  any  relation  to  the  pres- 
ence or  absence  of  the  mental  disorder.  There  were  in 
this  case  thirteen  attacks — one  each  year — at  first  in  the 
spring  season,  but  later  in  the  autumn  or  summer. 

Here,  too,  as  is  not  UQcommou  in  this  interesting 
type  of  melancholia,  the  suddenness  of  the  ending  of 
the  disorder  is  worthy  of  remark. 

Case  VII. — An  autumnal  example  of  recurrent  melan- 
cholia was  seen  by  me  many  years  ago  in  a  male,  aged  thirty- 
seven  years,  a  planter,  living  in  a  highly  malarious  part  of 
South  Carolina.  He  came  of  a  family  exceptionally  free 
from  insanity  and,  too,  from  all  other  neuroses.  At  the 
age  of  twenty-four,  in  June,  after  a  period  of  emotional 
distress,  he  became  melancholic.     In  the  autumn  he  made 


MELANCHOLIA.  41 

a  good  recovery,  and  resumed  his  business.  Two  years 
later  from  October  he  had,  without  known  cause,  three 
months  of  apathetic  melancholia.  This  relocated  itself 
two  successive  autumns.  Then  he  had  no  more  until  he 
was  thirty-one,  when  he  had  again,  in  the  month  of  Sep- 
tember, an  ague,  and  after  it  four  months  of  simple  melan- 
cholia. I  saw  him  when  he  was  aged  thirty-eight,  and  he 
had  then  had  three  years  in  sequence  autumnal  melan- 
cholia, never  outlasting  the  winter.  I  studied  his  case  in 
the  last  attack.  His  urine  was  loaded  with  dumb-bell  ox- 
alates, and  had  at  times  urates  or  uric-acid  crystals ;  but 
none  of  these  deposits  were  persistent.  His  state  of  stomach 
caused  me  to  advise  a  skim-milk  diet.  Under  this,  as  usual, 
all  uric  acid  and  oxalates  disappeared,  but  the  melancholia 
was  none  the  better.  Anti-periodics,  such  as  quinine  and 
arsenic,  had  proved  of  no  service,  but  he  was  sure  that  he 
escaped  attacks  if  he  went  north  in  summer  and  remained 
until  January.     I  know  nothing  of  his  later  history. 

I  have  met  with  other  less  striking  examples  of  sea- 
sonal (usually  spring-time)  melancholia.  I  have  seen 
others  in  which  melancholia  was  one  of  the  cyclic 
changes  of  circular  insanity,  but  in  which,  or  at  least  in 
two  cases,  the  melancholia  began  always  in  the  spring, 
and  was  replaced  in  summer  by  a  state  of  wild  excit- 
ability, the  midwinter  months  being  free  from  any  dis- 
tinct disorder  of  mind. 

The  simpler  cases  are  to  me  of  great  interest  At 
my  clinics  the  seasonal  relations  of  certain  neuroses  have 
in  the  past  been  studied  with  care  by  Dr.  Morris  Lewis, 
Dr.  Sinkler,  and  myself,  and  it  is  possible  that  some 
such  study  of  the  time  of  onset  of  non-recurrent  melan- 
cholias may  prove  of  interest  and  value.  So  far,  my 
own  cases  have  yielded  to  the  most  careful  study  no 
explanation  of  their  recurrence  at  a  certain,  or  near  a 

4* 


42  NERVOUS  DISEASES. 

certain  time  of  year.  Undoubtedly  they  were  not  of 
merely  lithsemic  parentage,  and  the  bare  fact  that  in 
these,  as  in  so  many  insane  people,  the  urine  is  at  times 
loaded  with  urates  or  free  uric  acid  or  oxalates  seems  to 
be  of  little  or  no  causal  moment.  I  think  that  Lange's 
authority  has  caused  too  much  importance  to  be  attrib- 
uted to  the  connection  between  melancholias  and  the 
presence  of  free  uric  acid. 

If  we  may  trust  the  statements  of  Pinel  and  some 
others,  there  is  in  chronic  insanities  a  tendency  to  ex- 
acerbations in  summer.  ^^  It  is  curious, ^^  says  Pinel, 
^'to  observe  the  effect  of  the  solar  influence  on  the 
return  and  march  of  the  larger  number  of  attacks  of 
mania''  (whether  he  means  only  the  wildly  insane  or 
includes  melancholias  is  not  clear);  ^Mt  is  common  to 
see  them  renew  themselves  with  more  or  less  violence 
during  the  months  which  follow  the  spring  solstice,  pro- 
long themselves  with  more  or  less  violence  during  the 
hot  season,  and  end  for  the  most  part  in  the  decline  of 
autumn.''^  He  adds  that  storms  excite  the  insane  of 
all  kinds,  a  question  which,  with  our  knowledge  of 
storms  and  our  complete  control  of  weather  statistics 
and  records,  should  become  at  once  a  matter  of  careful 
and  considerate  study  in  some  of  our  great  asylums. 

In  looking  through  the  literature  I  find  many  reports 
of  irregularly  recurrent  melancholias,  as  of  several  brief 
attacks  in  every  year  and  the  like,  but  as  to  seasonal 
melancholias  I  find  little  that  is  satisfactory.  Henry  M. 
Hurd  reports  two  in  the  American  Journal  of  Insanity. 
One  of  these  began  in  July,  1883,  and  quickly  got  well. 
The  second  attack  lasted  a  month  from  June,  1886. 

1  Is  this  the  case  with  us? 


MELANCHOLIA.  43 

Then  they  came  on  in  successive  years  in  May,  April, 
March,  and  August,  lasting  two  or  three  months  in  each 
case.  These  were  onsets  of  melancholia  agitata  with 
delusions.  The  rest  of  the  year  is  stated  to  have  been 
a  time  of  entire  sanity. 

Schule,  Klinische  Psychiatric,  1886,  has  an  interest- 
ing article  on  periodical  melancholia,  in  which,  while 
he  speaks  of  the  singular  abruptness  of  onset  and  ter- 
mination of  some  of  these  attacks,  and  of  their  being 
not  rarely  regular  as  to  seasonal  times  of  occurrence, 
he  does  not  state  the  season  in  which  they  are  most 
likely  to  obtain.  He  adds  that  periodical  manias  are 
for  certain  patients  so  regular  in  their  recurrence  that 
the  sufferer  can  with  correctness  count  on  their  coming 
in  certain  months.  I  do  not  know  of  any  later  and 
complete  study  of  this  subject,  and,  in  fact,  that  which 
I  have  thus  stated  is  incomplete  and  is  lacking  in  such 
detail  as  is  desirable.  Here,  again,  is  a  subject  to 
which  some  one  in  the  great  asylums  should  give  present 
attention. 

Pinel  and  Calmeil  have  as  to  these  points  certain 
statistics  which  seem  to  show  that  admissions  are  more 
frequent  in  spring  and  summer  in  France;  but  these 
would  be  more  valuable  if  in  place  of  admission  dates 
we  had  dates  of  the  outbreaks,  and  still  more  desirable 
if  we  had  such  statistics  in  regard  to  our  OAvn  country, 
and  as  to  climates  which  vary  from  ours  and  from  that 
of  France.  I  have  been  told  that  recurrent  seasonal 
melancholias  are  not  quite  so  unusual  in  Cuba  as  with 
us,  and  that  they  are  apt  to  come  on  with  the  hot 
weather  and  to  pass  away  with  the  cold.  T  have  seen 
recently  one  such  case  from  Cuba,  in  which  the  melan- 
cholia came  in   several   successive   years — I  think  as 


44  NER  VO  US  DISEASES. 

many  as  six — in  the  month  of  ^lay,  and  ended  always 
about  the  first  of  January.  The  obvious  indication  in 
all  these  cases  would  be  a  change  of  climate/  but  I  do 
not  know  of  any  case  in  which  this  has  been  employed, 
except  in  the  interesting  autumnal  example  which  I 
have  already  quoted.  Nor,  may  I  add,  do  I  know  of 
any  other  example  of  seasonal  melancholia  in  the  au- 
tumn, though  it  is  quite  possible  that  the  experience  of 
some  of  our  Southern  physicians  might  furnish  me  with 
instances,  aud  perhaps  even  of  such  as  can  be  shown 
to  be  distinctly  related  to  the  presence  of  malaria. 

The  effect  of  the  normal  menstrual  function  on  the 
increase  of  melancholia  already  present  is  well  known; 
but  I  do  not  find  it  stated  anywhere  tliat  some  per- 
sistent melancholias  in  women  are  extraordinarily  bet- 
ter at  this  very  time,  and  that  the  gloom  deepens  again 
during  the  interval  between  two  menstruations.  The 
two  cases  of  which  I  have  notes  were  young  married 
women.  Both  were  unusually  simple  examples,  and 
both  recovered  after  a  year.  It  must  be  common 
knowledge  among  observant  physicians  that  many 
women  are  depressed  and  gloomy  during  the  menstrual 
period;  but  there  are  also  cases  in  which  a  brief  but 
typical  melancholia,  with  or  without  delusions,  and  in 
some  with  suicidal  tendencies,  does  develop  at  this 
time  and  last  for  a  tew  days.  As  interesting  are  the 
menstrual  melancholias  with  erotic  tendencies,  or  those 
which  are  homicidal. 

Case  VIII. — C  B.,  of  California,  a  single  woman,  in 
easy  circumstances,  aged  thirty-four  years,  in  perfect 
health ;  had  no  family  history  of  insanity  that  could  be 

1  In  one  of  Dr.  Starr's  cases  this  proved  of  no  value. 


MELANCHOLIA.  45 

traced.  The  father  died  of  locomotor  ataxia,  Avith  no 
history  of  syphilis.  Of  late  years  during  menstruation 
she  had  had  a  quite  profound  and  increasing  melancholia. 
For  a  long  time  she  succeeded  in  hiding  this,  and  the  more 
distressing  phenomena  which  later  accompanied  the  condi- 
tion ;  but  about  the  date  I  have  mentioned  it  became  by 
degrees  an  agitated  state,  quite  uncontrollable,  and  in  which, 
amid  tears  and  lamentations,  she  struggled  with  wild  sexual 
desires.  One  or  more  sexual  dreams  contributed  at  these 
seasons  to  her  self-reproach  and  sense  of  impurity.  About 
the  sixth  and  last  day  she  began  to  lose  the  erotic  impulses 
and  to  talk  of  suicide.  At  the  eighth  day  she  was  free 
from  all  mental  and  moral  disorder  and  in  possession  of 
her  usual  entire  health  of  mind.  After  two  years  of  this 
torment  she  gladly  consented  to  lose  her  ovaries.  She  made 
a  good  recovery,  under  Goodell's  care,  but  was  physically 
feeble  for  a  year.  The  ovaries,  I  may  add,  were  seri- 
ously diseased.  For  three  years  after  their  removal  she 
had  slight  feelings  of  gloom  and  headache  at  the  time  when 
the  usual  term  of  ovulation  would  have  come  round  under 
natural  circumstances.  Then  by  degrees  she  ceased  to 
have  any  further  trouble,  and  has  now  been  for  many 
years  a  perfectly  strong,  efficient,  and  vigorous  woman. 

Not  all  such  procedures  are  so  fortunate.  Generally, 
this  operation  gives  temporary  or  no  relief  when  the 
melancholia  is  constant  and  is  merely  accentuated  by 
the  return  of  the  monthly  flow.  I  know  of  many,  far 
too  many,  cases  where  physicians  have  advised  and 
women  have  consented  to  the  removal  of  ovaries  under 
these  conditions,  and  where  no  relief  has  come  about  in 
consequence  of  the  operation. 

Homicidal  melancholias  confined  to  the  menstrual 
epoch  are  rare. 


46  NER VO  US  DISEASES. 

Case  IX. — ^liss  C,  of  Maine,  aged  forty  years,  single, 
in  easy  circumstances ;  came  of  a  family  most  of  whom  in 
her  generation  had  been  insane.  At  the  age  named,  being 
then  a  large,  ruddy  woman,  in  notably  good  health,  she 
was  alarmed  to  find  that  she  was  becoming  depressed  and 
melancholic.  This  condition  was  absolutely  limited  to  the 
period  of  menstruation,  and  did  not  begin  until  she  had 
been  flowing  for  a  day.  At  first  the  trouble  was  by  no 
means  profound,  and  there  was  none  between  her  monthly 
flows ;  but  later  at  these  periods  she  began  to  have  furious 
hysterical  convulsions,  with  visions  of  men  covered  Avith 
blood,  and  began  to  wish  to  kill  some  one,  and  this  usually 
a  person  dear  to  her.  This  state  continued  for  quite  a 
year,  and  in  the  interval  between  her  periods  she  was  in 
a  condition  w^hich  I  should  call  one  of  melancholy  with 
occasional  hysterical  convulsions  rather  than  of  melan- 
cholia. She  was  depressed  by  the  belief  that  her  family 
calamity  had  at  last  come  upon  her.  But  during  the  in- 
tervals she  had  none  of  the  delusions,  nor  of  the  maniacal 
melancholia,  which  oppressed  the  time  of  the  menstrual 
flow. 

At  this  later  period  an  examination  showed  that  both 
ovaries  were  enlarged.  They  were  skilfully  removed,  with 
the  tubes,  by  my  friend,  the  late  Professor  Goodell,  and 
were  found  to  be  full  of  cysts,  and  one  of  them  to  be  three 
inches  in  diameter,  while  the  other  was  at  least  six.  The 
effect  of  this  operation  was  astonishing.  The  attacks  ceased 
quite  abruptly,  the  intercurrent  distress  of  mind  faded 
away,  and  she  has  had,  after  nine  years,  no  further  trouble 
of  this  nature.  I  have  rarely  seen  a  more  amazingly  com- 
plete relief. 

More  unusual  are  the  cases  of  melancholia  which 
exist  only  during  a  portion  of  the  inter-menstrual 
period.  I  saw  one  such  case  in  consultation  many  years 
aiio: 


MELANCHOLIA.  47 

Case  X. — The  patient,  a  native  of  Alabama,  was  aged 
about  forty-two  years,  the  mother  of  seven  children,  and, 
until  her  forty-second  summer,  was  in  good  health.  At 
about  this  time  she  had  an  attack  of  some  kind  due  to 
heat.  There  was  great  exhaustion,  and  for  a  week  high 
temperature,  followed  by  a  good  recovery,  wdth  the  com- 
mon, subsequent  sensitiveness  to  solar  heat.  Two  months 
after  recovery  she  began  to  be  depressed,  and  later  this 
grew  into  typical  melancholia,  with  mild  delusions  as  to 
past  crimes,  great  self-depreciation,  and  the  like.  All  of 
these  faded  away  on  the  second  day  of  what  was  a  full 
but  quite  normal  menstrual  flow.  The  recovery  was  really 
abrupt  and  complete.  A  week  after  the  cessation  of  the 
flow  the  melancholia  began  again,  and  within  three  days 
became  grave.  It  was  at  times  suicidal,  although  this 
never  resulted  in  any  distinct  effort  at  self-destruction. 
This  sequence  repeated  itself  many  times.  I  do  not  know 
how  the  case  ended. 

Case  XL — The  second  of  these  interesting  cases  was  that 
of  an  intelligent  girl,  aged  eighteen  years,  handsome  and 
healthy  as  to  ap2:>earance  and  as  to  function  normal.  She 
came  of  a  family  in  which  there  was  and  had  been  much  in- 
sanity, more  eccentricity,  and  some  persons  of  great  ability. 
At  the  age  mentioned  Miss  K.  became,  in  June,  without 
known  cause,  furiously  maniacal.  Within  a  month  this 
became  less  and  less,  and  she  remained  in  a  state  of  deep 
dejection,  speechless  and  motionless,  often  with  a  positive 
rain  of  tears.  As  time  wore  on  it  was  seen  that  two  days 
before,  during,  and  after  the  menstrual  flow  Miss  K.  was 
increasingly  brighter.  After  seven  months  this  was  so 
remarkably  persistent  that  at  the  time  of  relief  she  read 
and  wrote  letters,  talked  and  heard  talk  with  pleasure,  and 
went  back  voluntarily  to  her  piano,  singing  and  playing 
with  taste  and  charm. 

The  second  year  found  this  lady  free  from  mental  dis- 


48  ^^ER  VO  US  DISEASES. 

order,  except  for  eight  days  midway  between  her  monthly 
flows.  At  this  time  she  was  silent,  or  even  speechless, 
tearful,  and  full  of  gloom.  Now  and  then  she  would 
write  an  answer  to  questions,  but  considered  it  wicked  to 
speak.  The  approach  of  the  menstrual  terra  brought  a 
rapid  increase  of  good  spirits,  and  during  the  flow  and 
later  she  was  thought  to  be  natural  by  those  who  knew 
her  best.  At  this  season  she  declared  that  the  time  of 
melancholia  was  never  so  distinct  in  her  memory  as  it 
might  have  been  expected  to  be.  She  forgot  its  details, 
and  seemed  to  suffer  very  little  from  the  recollection  of 
what  she  had  gone  through.  This  is  a  merciful  and  not 
a  rare  feature  of  many  forms  of  mental  disorder.  The 
impression  they  leave  on  the  memory  has  the  evanescent 
quality  of  the  mind's  record  of  a  dream. 

When  this  case  had  lasted  in  this  state  for  two  years  I 
saw  her  in  consultation  with  the  late  Professor  Charles  D. 
Meigs.  He  Avas  strongly  of  opinion  that  she  should  be 
bled  in  the  interval,  and  accordingly  she  was  bled  some 
twenty  ounces  about  ten  days  after  the  flow  ceased,  and 
was  also  put  permanently  on  a  diet  chiefly  vegetable. 
After  the  first  bleeding  the  sequent  depression  in  the 
middle  of  the  month  was  less,  and  after  four  successive 
bleedings,  which  were  done  much  closer  to  the  time  of  the 
expected  attack,  it  became  insignificant.  I  then  sent  her 
on  a  long  ocean  voyage,  during  which  her  convalescence 
became  complete.  She  died  fourteen  years  after,  from 
an  acute  intestinal  malady,  but  had  never  any  return  of 
inter-menstrual  or  other  disorder  of  the  mind.  I  ought  to 
state  that  long  before  the  lancet  was  used  a  great  variety 
of  treatment  had  been  resorted  to,  and  that  nothing  had 
been  left  undone  which  I  could  devise  to  break  up  these 
attacks. 

I  am  reminded  by  this  case  of  three  occasions  on  w^hich 
suicidal  failures,  causing  immense  loss  of  blood,  resulted 


MELANCHOLIA.  49 

in  rapid  relief  in  melancholias  of  the  gravest  types.  I 
have  seen  another  within  a  very  few  days  of  this  writing. 
I  leave  these  facts,  which  I  have  not  time  here  to 
discuss,  to  the  ingenious  interpretation  of  others.  I 
pass,  in  this  brief  summary,  to  the  cases  of  melancholia 
which  seemed  to  have  some  relation  to  sleep  or  its  phe- 
nomena. In  the  year  1895  I  read  to  the  Association 
of  Physicians  and  Pathologists  a  paper  on  the  Disor- 
ders of  Sleep.  I  then  classified  the  mental  phenomena 
arising  out  of  dreams,  or  out  of  what  I  called  the 
prce-  or  the  post-dormitlum.  At  this  time  I  drew  atten- 
tion to  Baillarger  as  the  only  author  who  had  realized 
the  importance  of  this  period,  the  post-dormitium,  in 
connection  with  insanity.  The  gteat  value  of  these 
facts,  and  of  those  I  added,  has  even  yet  failed  to 
attract  further  contributive  illustrations.  The  cases  I 
reported  were  chiefly  of  hallucinations  of  the  senses. 
Since  then  I  have  seen  a  number  of  instances  in  which 
the  post-dormitium  was  haunted  by  sensory  delusions  of 
painful  character,  followed  by  an  hour  or  two  of  really 
deep  melancholia  in  a  waking  state.  It  is  familiar 
knowledge  that  melancholias  are  worst  on  awaking,  but 
instances  of  this  brief  melancholia  either  preceded  or 
not  by  sensory  post-dormitial  hallucinations  are  more 
rare.     A  single  case  will  suffice: 

Case  XII. — C.  J.,  clergyman,  of  Connecticut,  aged 
sixty-five  years,  had,  twenty  years  before,  a  long  and 
severe  spell  of  simple  melancholia.  At  this  later  date,  in 
the  early  spring,  he  began  to  have,  befoVe  he  was  fully 
awake,  delusions  as  to  voices  reproaching  him.  With 
these  were  visions  of  droll  or  horrible  faces.  When  he 
became  fully  conscious  these  left  him,  upon  opening  his 
eyes,  but  for  awhile   i*eturned  if  he  again   closed    them. 

5 


50  NER  VO  US  DISEASES. 

A  few  miuiites  later  the  sounds  and  visions  left  him  en- 
tirely, but  for  two  hours  he  was  the  victim  of  a  melan- 
cholia so  deep  as  to  be  once  or  twice  almost  overwhelm- 
ingly suicidal.  About  11  a.m.  this  all  passed  away,  and 
he  became  so  well  as  to  be  able  to  attend  competently  to 
important  duties  during  the  rest  of  the  day.  These  phe- 
nomena lasted  for  years  at  intervals,  and  finally  ended  in 
senile  dementia  of  the  passive  type. 

I  have  also  seen  remarkable  instances  of  temporary 
but  really  profound  melancholias  which  were  the  out- 
come of  dreams.  I  recall  two  such  cases.  It  may 
answer  to  relate  one.  The  borderland  of  unsoundness 
of  mind  is  sometimes  subject  to  a  great  increase  in  the 
number  of  dreams,  and  these  may  be  so  constantly 
horrible  or  terrifying  as  to  be  a  w^arniug  of  the  coming 
mental  disaster,  as  has  been  more  than  once  pointed  out, 
especially  by  Baillarger.  It  is,  however,  uncommon  to 
find  the  dream  resulting  in  an  attack  of  agitative  or 
simple  melancholia.  Abnormal  fear,  irrational  anxiety, 
may  come  of  it,  but  not  often  distinct  melancholia. 

Case  XIII. — Mr.  L.,  aged  thirty  years,  an  engineer, 
consulted  me  on  account  of  nocturnal  attacks.  Except 
that  he  had  frequent  ophthalmic  megrim,  he  was  in  good 
health  and  free  from  evil  hereditations.  After  a  period  of 
great  commercial  anxiety  he  had  one  night  a  dream  of 
falling  from  the  trestle  of  a  bridge.  He  awoke  sweating 
and  in  a  state  of  wild  agitation.  He  said  that  he  rose,  lit 
up  the  room,  and  began  to  walk  about.  His  affairs  seemed 
to  him  hopelessly  involved ;  he  figured  himself  as  weak, 
incapable,  and  untrustworthy.  Life  seemed  unendurable. 
He  cried  like  a  child,  and  at  last  drank  a  tumbler  of 
brandy  and  fell  asleep.  This  torment  came  again  at  in- 
tervals of  weeks  or  months,  and  later ^ on  became  frequent. 


MELANCHOLIA.  51 

The  dreams  varied,  but  the  results  were  the  same.  A 
summer  in  the  woods  brought  relief,  and  an  ocean  voyage 
finally  rid  him  of  this  disorder, 

I  shall  close  this  too  condensed  statement  of  certain 
of  the  unusual  ways  in  which  melancholias  arise  with 
a  single  example  of  its  production  during  digestion^  in 
a  case  of  intermittent  glycosuria: 

Case  XIV. — H.  R.,  aged  about  forty  years,  a  scholar  of 
uncommon  ability,  consulted  me  for  a  condition  then  and 
since  unknown  to  my  experience.  He  had  been  for  years 
a  dyspeptic,  suffering  much  with  a  sense  of  weight  at  the 
epigastrium,  with  wind  and  excess'of  acid.  Within  a  few 
months  the  dinner  at  7  p.m.  was  followed  by  the  usual 
distress,  but  later,  about  9  p.m.,  by  deep  dejection,  indif- 
ference to  life,  desire  to  be  alone,  tears,  and  what  he  called 
"fragments  of  delusions,"  easily  disposed  of  by  the  reason, 
but  apt  to  return.  This  condition  passed  away  about  12 
at  night,  and  he  usually  slept  well.  These  attacks  became 
of  daily  occurrence  and  were  more  or  again  less  severe. 
It  was  soon  found  that  he  had  sugar  in  his  urine ;  that  the 
quantity  was  least  on  rising  from  sleep  in  the  morning ; 
that  it  increased  after  meals,  and  was  largest  about  two  or 
three  hours  after  dinner,  the  time  at  which  his  melancholia 
arose  and  deepened.  A  long  course  of  skimmed-milk 
diet  was  of  great  service,  and  later,  by  eating  a  carefully 
chosen  diet  six  times  daily,  he  did  very  well,  escaping  for 
a  long  period  both  the  glycosuria  and  the  mental  disorder, 
which  appeared  in  the  evenings  and  seemed  to  be  related 
to  a  rise  in  the  amount  of  excreted  sugar.  He  died  of 
double  pneumonia  some  years  later. 

I  recall  no  other  case  of  melancholia  clearly  related  to 
digestive  troubles,  or  to  glycosuria;  nor  do  I  think  that 
ordinary  cases  of  the  mental  disease  suffer  more  after 


52  ^ER  VO  US  DISEASES. 

meals.  The  early  morning  hours  are,  as  all  alienists 
know,  the  time  of  greatest  misery ;  the  chosen  hours  for 
suicidal  thoughts  or  efforts.  When  this  sequence  is 
reversed  and  the  evening  is  the  time  of  gloom  we  have, 
as  a  rule,  to  deal  merely  with  the  dejection  met  with 
in  some  neurasthenics  or  hypochoudriacs,  or  witli  an 
hysterical  simulation  of  melancholia. 


CHAPTER   III. 

IRREGULARLY  RECURRENT  MELANCHOLIA  WITH  LONG 
INTERVALS  AND  NOT  IN  APPARENT  RELATION  TO 
FUNCTION. 

Perhaps  there  is  no  more  reason  to  be  surprised  at 
melancholias  which  recur  after  a  day  or  days  of  sanity, 
than  as  to  those  which  return  after  months  or  years. 
In  cases  like  that  quoted  at  tlie  close  of  the  last  lesson 
the  regular  repetition  of  melancholia  in  connection 
with  the  time  of  digestion  tempts  the  reason  with  pos- 
sibilities of  explanation;  but  in  the  cases  to  which  I 
now  refer,  and  shall  illustrate  with  a  striking  example, 
no  form  of  explanation  as  yet  seems  available.  ]N"ever- 
theless,  it  is  in  the  careful  study  of  such  melancholias 
and  their  sequent  intervals  of  soundness  of  mind  that 
we  are  offered  the  best  chance  of  discovering  the  agen- 
cies which  can  so  quickly  develop  a  mental  disorder. 

The  following  case  sought  advice  while  I  was  writing 
this  paper.  It  is  an  example  of  recnrrent  melancholia 
of  brief  duration,  returning  every  two  or  three  days, 
and  lasting  four  hours  to  twenty  hours: 

Case  XV. — C.  E.,  retired  merchant,  aged  sixty-five 
years,  married.  The  father  was  healthy,  and  died  aged 
eighty- eight  years;  mother  healthy,  died  aged  eighty-four 
years.  Three  sisters  are  alive  and  well.  Three  brothers 
died  aged  respectively  seventy-five,  seventy-four,  and 
thirty-eight  years ;  one  nephew  had  melancholia  with 
delusions. 

Had  had  typhoid  fever  in  1870 — no  sequelae ;  habits 
5- 


54  ^^^  VO  US  DISEASES. 

good  ;  uo  syphilis.  For  fifteen  years  has  been  liable 
to  feel  depressed  when  his  business  became  troublesome, 
or  in  commercial  crises.  His  general  health  is  unusually 
good.  The  heart  and  arteries  are  far  better  than  is 
common  at  his  age.  He  is  clear  of  head,  competent  in 
business,  sleeps  well.  His  appetite  is  good  ;  his  bowels 
regular.  Is  liable  to  occasional  indigestion,  with  non- 
acid  eructations.  He  has  normal  reflexes ;  his  station 
is  perfect.  The  urine  shows  no  albumin  or  sugar.  The 
morning  urine,  on  standing,  presents  a  small  deposit  of 
free  uric  acid  and  urates.  The  attacks  I  shall  describe 
have  no  relation  to  the  meal-times.  When  away  from 
home  they  are  fewer  in  number,  but  except  as  to  this  he 
knows  of  nothing  which  affects  the  number  or  severity  of 
the  spells. 

About  five  years  ago  Mr.  E.  began  to  have  brief  attacks 
of  mild  melancholia.  They  came  at  irregular  intervals — 
weeks  apart.  A  year  later  their  frequency  and  intensity 
increased,  until  ever  since  they  have  continuously  recurred 
two  or  three  times  a  week.  The  longest  interval  is  five 
days.  They  may  repeat  themselves  every  day,  on  two  to 
four  successive  days,  or  return  upon  alternate  days  with 
regularity.  The  seasons  do  not  affect  their  number,  nor 
does  the  time  of  day.  He  may  awaken  in  an  attack ;  he 
may  have  one  at  evening,  and  lose  it  in  the  sleep,  w^iich 
it  does  not  seem  to  make  less  sound.  He  can  neither 
avoid  these  spells  nor  lessen  their  force  or  shorten  them. 
From  the  time  he  first  feels  the  attack  or  sense  of  dejection 
to  its  climax  about  half  an  hour  elapses.  It  passes  away 
even  more  abruptly  at  times,  but  commonly  is  an  hour  in 
leaving  him,  dating  the  time  from  a  sense  of  distinct  relief 
to  full  possession  of  his  natural  cheerfulness. 

While  thus  afflicted  he  is  melancholy,  irritable,  turns 
over  and  over  in  mind  every  possible  source  of  annoyance, 
even  conjuring  up  the  worries  of   others   with  which  to 


MELANCHOLIA.  55 

perplex  himself.  At  these  times  he  must  be  alone ;  will 
see  no  one ;  contemplates  suicide,  but  has  made  no  suicidal 
attempt  and  does  not  believe  he  ever  will.  This  dejection 
he  describes  as  profound,  and  says  that  hope  seems  dead, 
affection  valueless,  and  life  a  torment.  He  has  no  delu- 
sions of  sense ;  then  there  is  a  feeling  of  relief,  and,  as  de- 
scribed, the  ''cloud  passes,"  and  he  is,  as  usual,  gay,  happy, 
and  equal  to  any  sport  or  work. 

To  illustrate  this  singular  case,  I  give  his  own  record 
of  twenty-two  successive  days  in  midwinter:  twelve 
were  free  from  attacks;  on  three  he  had  brief,  mild 
spells.  He  had  six  sharp  attacks,  and  one  of  great 
severity  both  as  to  length  and  excess  of  melancholy. 

Prof.  Samuel  Jackson  described  a  case  not  purely  or 
very  distinctly  melancholia,  which  recurred  alternate 
weeks  with  sane  intervals,  and  ended  in  dementia.  I 
can  find  nowhere,  however,  a  melancholia  which  repeats 
the  phenomena  of  the  case  I  have  given. 

This  gentleman  returned  January  12,  1897,  to  permit 
of  study  of  his  days  of  melancholia  as  compared  with  the 
normal  intervals.  Unluckily,  but  as  is  usual  with  him 
when  aAvay  from  home,  he  had  fewer  attacks — in  fact  but 
two  in  the  fortnight  of  his  stay. 

Study  of  his  secretions  by  Dr.  Pearce  began  by  an 
examination  Avhich  gave  the  following  results :  He  was 
feeling  well ;  pulse  72  and  respiration  18  ;  temperature, 
98.5°  ;  blood-count,  4200,000  ;  hemoglobin,  90,  at  11  p.m. 

The  urine  for  twenty-four  hours  was  over  the  normal,  as 
he  weighs  140  pounds  ;  amount,  forty-five  to  fifty-five 
ounces  ;  specific  gravity,  1020.  No  abnormal  constitu- 
ents except  amorphous  phosphates  were  thrown  down 
after  the  urine  stood  a  few  hours.  At  this  time  he  looked 
well  and  ruddy,  and  was,  as  usual,  gay  and  cheerful. 


56  NER  VO  US  DISEASES. 

Ou  January  20tli  he  had  an  attack :  notes  taken  at  10 
to  11  P.M. 

He  had  been,  as  he  said,  ' '  fine  "  until  late  this  after- 
noon, when  he  began  to  feel  badly.  Did  not  wish  to 
speak  to  anybody  or  exert  himself.  Noticed  nervous 
cough  and  accumulation  of  sticky  mucus  in  throat  and 
feeling  of  depression  about  the  "  brain"  and  of  pressure 
over  sternum.  Did  not  care  to  go  to  "opera"  on  account 
of  this  "  cloud  "  settling  over  him.  Went  to  bed  and  slept, 
but  awoke  in  two  hours  in  a  dreamy  state  with  feeling  of 
despair  and  discouragement,  the  "cloud"  or  haze  gradu- 
ally falling  over  him  until  the  mental  depression  was 
almost  unbearable,  and  he  was  afraid  he  would  be  an 
"imbecile."  Unnatural  dread  of  the  little  preparation 
to  go  home.  Could  not,  through  any  effort,  throAV  off  the 
feeling. 

When  seen  at  10.30  p.m.  the  eyes  were  dull  and  red, 
the  pupils  equal  and  resj^ionded  sluggishly  but  equally ; 
station  good ;  knee-jerks  normal ;  respirations  regular,  18 
per  minute  ;  pulse  full,  compressible,  72  per  minute  ;  tongue 
clean  and  moist ;  temperature  subnormal,  97.6°  F. 

January  21st,  reports  attack  as  passing  off  while  Ave  were 
talking  together  at  11  p.m.  Slept  well;  awoke  at  7  a.m. 
Feels  "fine."  Says  he  could  do  business  to-day  better 
than  usual,  being  clear  and  competent.  Four  ounces  of 
urine  were  saved  during  the  attack. 

During  the  day  of  onset  the  quantity  of  urine  fell  to 
thirty- three  ounces.  In  another  minor  attack  it  was  in 
excess — fifty-five  ounces. 

While  in  mental  health  he  passed  ratlier  less  urea  than 
is  usual ;  in  both  the  attacks  it  was  materially  lessened. 
The  percentage  of  uric  acid  was  decidedly  increased  in 
the  more  severe  attacks,  but  not  in  the  milder.  Indican 
was  certainly  present  in  larger  amount  in  the  urine  of  the 


MELANCHOLIA.  57 

melancholias  than  in  that  passed  while  free  from  depres- 
sion, when  only  a  trace  was  detected. 

I  complete  this  notable  case  with  a  table  of  the  days 
of  melancholia  noted  during  1896: 

In  January  there  were  nine  bad  days ;  February,  six ; 
March,  ten  ;  April,  thirteen  ;  May,  eight ;  June  not  given, 
but  said  to  be  a  bad  month ;  July,  ten  ;  August,  five  ; 
September,  three ;  October,  nine ;  November,  five ;  De- 
cember, eight.  Evidently  the  spring  and  summer  months, 
up  to  August,  were  the  worst. 

Unfortunately,  this  gentleman  was  called  away  before 
he  gave  us  any  further  opportunity  to  study  his  case, 
and  it  were  unwise  to  draw  conclusions  from  these  im- 
perfect chemical  analyses. 


CHAPTER   IV. 

SOME    DISORDERS   OF   SLEEP. 

When  dealing  with  organs  or  functions  the  physi- 
ology of  which  we,  in  a  measure  at  least,  comprehend, 
it  becomes  easy  and  pleasant  to  discuss  their  alterations 
from  health;  but  as  regards  sleep  we  know  little.  The 
wildest  theories  have  been  entertained  concerning  it; 
and,  after  all,  we  are  simply  driven  to  believ^e  that  it 
is  a  state  of  the  nerve-cells — and  why  not  of  the  nerves  ? 
— in  which  they  become  functionally  actionless  in  a 
variable  degree.  Whether  this  be  true  also  of  the  other 
cell-structures  of  the  body  we  do  not  know;  and  sleep 
may  be  a  universal  function,  as  would  seem  reasonable 
to  those  who  believe  that  plants  sleep.  It  is  sure,  also, 
that  the  sleeping  brain  contains  less  blood,  or  that  it 
circulates  less,  than  the  brain  awake,  and  this  is  the 
limit  of  what  we  know. 

The  disorders  of  sleep  are  many.  I  have  found  my- 
self driven  to  choose  among  them,  and  I  shall  limit 
myself  to  a  less  known  group,  to  some  members  of  which 
I  was  the  first  to  call  attention. 

In  1876^  I  described  several  of  the  morbid  states  of 
sleep,  and  again  Avrote  of  them  more  freely  in  1878.^ 
In  1882,  in  my  lectures  on  Xervous  Disorders  of 
Women,  I  dwelt  at  greater  length  on  the  symptoms 
in  question,  as  well  as  on  others  which  have  been  much 

1  Philadelphia  Medical  Reporter,  1876. 
-  Virginia  Medical  Journal,  1878. 


SOME  DISORDERS  OF  SLEEP.  59 

discussed  of  late  in  the  journals  ^vitliout  notable  addi- 
tions of  value. 

In  making  choice  of  how  I  shall  treat  of  sleep-troubles 
I  have  been  influenced  somewhat  by  the  fact  that  certain 
of  these  it  has  been  my  fortune  to  see  and  to  study  more 
than  I  have  the  better  known  phenomena  of  dreams, 
somnambulism,  and  the  like. 

The  approach  to  the  unconsciousness  of  slumber,  and.^ 
too,  the  return  from  it  to  the  world  of  volition,  may  be 
medically  considered  as  part  of  sleep,  and,  as  I  shall 
show,  these  periods  are  often  disturbed  by  certain  very 
interesting  symptoms. 

As  we  are  falling  asleep  the  senses  go  off  guard  in 
orderly  and  well-known  succession — this  interval  I  de- 
sire to  label  the  prce-dormltium.  When  we  begin  to 
awaken,  and  the  drowsied  sentinels  resume  their  posts, 
there  is  again  a  changeful  time,  during  which  the  mind 
gradually  regains  possession  of  its  powers — this  interval 
I  may  call,  in  like  fashion,  the  post-dormitium. 

The  Relation  of  the  Prse-dormitium  to  Insanity. 
In  the  borderland  of  coming  slumber,  when  we  are 
not  yet  overwhelmed  by  its  full  power,  the  steadying 
contradictions  of  the  external  world  are,  in  a  measure, 
by  degrees  cut  off,  whilst  the  will  still  holds  a  slowly 
lessenino^  rule.  It  has  Ions:  been  known  to  alienists  that 
the  prse-dormitium  is  apt  to  be  invaded  by  hallucina- 
tions in  those  who  are  becoming  disturbed  in  mind. 
Every  student  of  himself  knows,  too,  what  a  fairy  coun- 
try for  visions  is  this  intermediate  state.  Since,  in  the 
sound,  it  is  the  time  for  castle-building,  it  seems  nat- 
ural that,  in  the  disordered,  it  should  serve  to  foster 
dangerous  hallucinations,  and  that,  in  rare  instances, 
these  should  be  limited  to  the  period  in  question.     Bail- 


60  ^^ER  VO  US  DISEASES. 

larger  is  the  only  author  who  has  studied  with  any  care 
the  relation  of  the  pr?e-dormitiuin  to  insanity.  Of  this 
he  says: 

'*The  organs  of  sense  ceasing  to  transmit  to  us  exterior 
impressions,  the  control  of  our  ideas  escapes  us,  and  what- 
ever rises  appears,  as  it  were,  spontaneous  ;  at  times  vague 
or  confused,  fantastic  forms  succeed  one  another,  and  we 
have  of  it  all  but  a  half-consciousness.  At  times  more 
distinct  forms  appear,  and  we  are  present,  as  it  were,  at  a 
strange  spectacle  in  which  we  take  no  active  share,  but 
which  leaves  distinct  traces  on  the  mind.  Any  exterior 
intervening  impression  causes  these  visions  to  vanish.  A 
sudden  noise,  or  touch,  or  light  awakens  fully  the  senses, 
recalls  attention,  and  these  phantoms  are  effaced."^ 

The  period  now  in  question  is  of  great  psychological 
interest;  nor  have  the  laws  which  control  it  been  studied 
enough.  In  childhood  it  is  certainly  the  time  of  easily 
attained  visions,  and  in  the  imaginative  this  is  especially 
the  case.  As  years  go  on  the  power  to  fill  this  magic 
interval  with  what  we  will  to  see  grows  less,  and  in 
later  years  is  materially  impaired  or  is  altogether  lost. 

I  have  been  at  some  pains  to  learn  to  what  extent  the 
capacity  to  call  up,  control,  and  dismiss  visions  exists 
in  the  prae-dormitium.  The  ability  to  project  visually 
at  will  on  the  screen  of  consciousness  greatly  varies 
with  the  individual.  Generally  in  youth  it  is  possible 
soon  after  closing  the  eyes  for  sleep  to  evoke  visions. 
Some  children  can  control  these  visions.  They  see  what 
they  will.  This  was  at  one  time  the  case  with  me. 
Others  may  will  in  vain.  They  see  nothing  or  only 
the  crude  stuff  of  dreams,  or  else  something  they  did 

1  Baillarger  :  Aunales  Med.  Psych.,  vols.  v.  and  vi. 


S03IE  DISORDERS  OF  SLEEP.  61 

not  seek  to  summon.  Few  can  hold  these  phantoms. 
They  come,  they  go,  change  and  vary  under  mysterious 
influences,  uncontrollable  by  the  will.  Such  is  apt  to 
be  the  case  later  in  life  for  all  who  continue  to  be  able 
to  possess  the  power. 

This  is  hardly  the  place  to  go  much  further  into  the 
physiology  of  the  prse-dormitium.  I  speak  of  it  only 
because  it  is  the  threshold  of  sleep  and  full  of  interest 
to  the  alienist,  and,  indeed,  to  the  neurologist. 

Even  this  brief  study  of  its  peculiarities  reminds  one 
of  the  prolonged  condition  into  which  we  are  brought 
by  the  action  of  moderate  doses  of  such  drugs  as  mescal 
— Anheloiiium  Lewinii.  The  original  study  of  this  drug 
by  Professor  Prentiss  and  a  later  examination  by  the 
author^  have  made  clear  the  remarkable  resemblance  of 
mescal  intoxication  to  the  natural  period  I  have  called 
the  prge-dormitium.  I  speak  here  with  assurauce  only 
as  to  myself,  for,  as  I  have  said,  we  as  yet  need  a  full 
study  of  the  psychology  of  the  states  which  precede 
and  follow  slumber. 

In  a  long  series  of  interesting  cases  Baillarger  shows 
that  certain  persons,  otherwise  still  sound,  are  liable  to 
have,  between  waking  and  sleep,  hallucinations  which 
long  precede  the  outbreak  of  insanity.  He  describes 
instances  of  such  hallucinations  of  sight  and  hearing  as 
lasting  from  one  to  three  years,  and  ending  in  grave 
mental  disease.  These  were  usually  voices  or  visions, 
fading  when  the  eyes  were  opened,  as  occurs  with  mes- 
cal visions.  In  one  case  there  Avas  something  like  the 
sense  of  a  blow  on  the  head,  and  then  on  the  bed,  but 
nothing  comparable  in  this  direction  to  the  phenomena 


British  Medical  Journal,  Dec.  5, 
6 


62  NER  VO  US  DISEASES. 

of  sensory  shocks  to  which  I  shall  presently  call  your 
attention. 

I  have  myself  seen  illustrations  of  the  facts  men- 
tioned, and  I  speak  of  them  here  because  this  is  ground 
we  rarely  go  over  in  our  examinations  of  patients.  It 
may  possibly  be  found  that  valuable  prognostic  indica- 
tions as  to  insanity  are  to  be  gained  by  examination  of 
the  prse-dormitium. 

Before  passing  on  to  other  matters  I  may  say  that 
generally,  as  I  have  known  them,  these  prodromes  of 
insanity  were  connected  with  eye  or  ear  alone.  In  but 
one  case  was  olfaction  concerned.  I  will  content  myself 
with  a  sketch  of  it: 

Case  XVI. — Mrs.  C,  aged  forty  years,  of  a  neurotic 
family,  all  liable  to  neuralgic  headaches.  One  brother 
died  of  ataxia.  Convulsions  in  infancy  were  common  to 
all  five  brothers  and  sisters,  none  ending  in  epilepsy. 
Mrs.  C,  who  was  well  except  as  to  headaches,  had  a  fall 
which  injured  her  nose.  The  shock  resulted  in  persistent 
headaches,  without  other  cerebral  trouble  save  complete 
loss  of  smell.  Two  years  later  she  had,  but  only  on  going 
to  sleep,  a  sense  of  horrible  odors,  which  were  fecal  or 
animal  and  most  intense.  This  lasted  several  months,  and 
then  were  added  sounds  of  voices,  which  were  at  first  vague, 
but  at  last  accusative,  and  soon  were  heard  in  the  day. 
The  case  ended  in  melancholia  with  delirium  of  persecu- 
tion, during  which  the  trouble  as  to  smell  passed  away. 

Case  XVII. — A.  C,  a  clever  lad,  of  exceptionally  able 
and  normal  descent,  became  insane  at  eleven  years  of  age, 
and  was  long  maniacal  and  often  homicidal.  For  some 
months  before  this  outbreak — which  was  acute — he  was 
troubled  by  seeing  animals  on  his  bed  before  he  fell  asleep. 
Opening   his  eyes   routed  them  at  once.     The  condition 


SOME  DISORDERS  OF  SLEEP.  63 

seemed  to  have  none  of   the  peculiarities  of   the   night- 
terrors  of  childhood. 

I  am  tempted  to  add  the  brief  notes  of  another  lad's 
case,  in  which  the  same  period  was  a  time  of  singular 
disorder  of  mind.  It  is,  of  course,  known  to  many  of 
you  that  the  bromides  may  in  some  persons  (and  notably 
in  the  young)  occasion,  like  mercaptan,  profound  melan- 
choly or  maniacal  tendencies,  which  in  several  instances 
in  my  experience  have  been  homicidal,  or  at  least  madly 
destructive. 

Case  XVIII. — The  lad  in  question,  an  epileptic,  aged 
eleven  years,  was  said  to  become  homicidal  from  bromides. 
I  was  skeptical  enough  to  test  the  matter.  About  the 
seventh  day  of  using  full  doses  of  lithium  bromide  the 
trouble  showed  itself  in  the  prjesomnic  time  as  visions  of 
himself  killing  other  children.  They  annoyed  him  greatly, 
so  that  he  strove  to  keep  awake ;  but  at  last,  tired  of  the 
unnatural  effort,  would  fall  asleep,  with  too  brief  an  interval 
to  allow  of  his  being  disturbed  again.  After  several  nights 
of  like  distress  the  homicidal  tendency  broke  out  in  abrupt 
and  dangerous  violence  during  the  daytime. 

There  are  epileptic  cases  in  which  inhibition  of  fits 
causes  homicidal  explosions  which  cease  when  the  fit 
comes  on,  and  do  not  recur  for  a  time,  whether  bro- 
mides are  continuously  used  or  not.  In  this  lad's  case 
the  fits  did  not  lessen  the  tendencies  to  destroy  or  injure 
others.  These  lasted  as  long  as  the  bromides  w^ere 
given.      I  think  Echeverria  mentions  like  cases. ^ 

There  exists  also,  I  may  say,  a  group  of  cases  (not  in 
the  books)  in  which  the  borderland  of  sleep  is  haunted 

1  Also  the  author.  See  On  Exceptional  ElFeets  of  Bromides.  Transactions 
of  Association  of  American  Physicians  and  Pathologists,  May,  1896.  University 
Medical  Magazine,  June,  1896. 


64  ^^'^-B  VO  US  BISEASES. 

by  hallucinations  for  weeks  or  years  without  their  end- 
ing of  necessity  in  mental  disease;  but  it  is  quite  im- 
possible for  me  here  at  this  time  to  dwell  on  these 
interesting  cases,  of  which  I  have  seen  a  few,  and  but 
a  few.  In  no  respect  do  they  differ  from  the  like  cases 
reported  by  Baillarger  in  which  insanity  resulted,  save 
in  the  fact  that  it  did  not.  Voices  were  heard  or  dis- 
tressing visions  seen  during  the  prse-dormitium,  and  at 
no  other  period.  AVith  time  and  due  care  these  vis- 
ions faded  away.  Tw^o  of  the  half-dozen  I  recall  were 
hysterical  women;  two  were  men  in  busy  affairs;  and 
one,  the  worst,  a  Avoman  of  thirty-seven  years,  was,  I 
think,  preserved  from  insanity  by  the  loss  of  her  ovaries. 

Tlie  corresponding  time,  which  comes  after  sleep  and 
before  full  wakefulness,  is  also  said  by  Baillarger  to  be 
troubled  in  some  by  hallucinations,  but  of  this  I  have 
no  experience;^  nor  does  he  speak  of  it  as  common. 
Tuke  also  has  reported  cases. 

There  is  yet  another  and  stranger  mental  condition 
experienced,  though  rarely,  in  the  prse-dormitium.  This 
is  a  suddenly  acquired  and  sometimes  persistent  sensa- 
tion of  fear  or  terror  without  any  sensory  hallucination. 
For  our  emotional  states  we  have  usually  a  cause,  or  at 
least  think  we  have;  but  what  I  now  describe  is  an 
emotion  without  known  parentage.  Children  may 
exhibit  this  continuous  fear  after  the  scare  of  a  dream, 
like  the  echo  of  an  emotion  the  cause  of  which  is 
over. 

Sometimes  in  adults  this  lasting  sense  of  alarm  is  the 
product  of  a  dream.  The  victim  awakens  and  continues 
even  for  hours  to  feel  the  fear  to  which  his  dream  gave 

1  See,  however,  as  to  this,  my  own  later  experience— chapter  on  Recurrent 
Melancholia— in  this  present  volume. 


SOME  DISORDERS  OF  SLEEP.  65 

rise.  He  is  wide  awake;  lights  the  lamp;  reads,  or 
tries  to;  but  is  still  fear-haunted,  reason  as  he  may. 
The  patient  who  is  liable  to  this  fear  may  also  be  sub- 
ject to  attacks  of  pure  fear  without  a  dream-cause,  and 
arising  in  the  time  between  waking  and  slumber.  He 
has  then  no  dream.  Of  a  sudden,  whilst  half-awake,  the 
man  is  afraid.  It  is  pure  fear,  such  as  the  insane  have 
at  times.  I  append  a  case  from  my  first  paper.  Both 
forms  of  the  trouble  here  mentioned  wTre  felt.  The 
case  is  given  as  stated  by  the  sufferer,  a  scholarly,  much 
overworked  man,  with  no  obvious  habits,  hereditations, 
or  disorders  to  explain  his  condition.      He  says: 

Case  XIX — "About  the  year  1871,  being  then  fifty-five 
years  old  and  in  sound  health,  I  was  troubled  with  what  I 
understand  to  be  '  night- terrors,'  but  unlike  any  I  have 
been  able  to  hear  of.  Upon  retiring  I  could  generally  tell 
whether  or  not  I  should  have  this  trouble  during  the  night. 
These  premonitions  were :  a  difficulty  in  breathing,  not 
being  able  to  draw  a  f  idl  breath,  owing,  as  it  seemed  to  me, 
to  some  obstruction  in  the  lungs ;  intense  nervousness ; 
turning  from  side  to  side. 

' '  I  would  fall  asleep  and  have  vivid  dreams,  and  almost 
always  upon  the  same  subject,  the  purport  of  which  was, 
that  after  long  absence  from  home  I  returned  and  found 
that  some  one  dear  to  me  had  become  idiotic. 

"The  most  painful  attack  of  this  kind  occurred  in  1872. 
That  night  I  dreamed  that  after  a  long  absence  I  returned, 
and,  upon  approaching  the  city,  I  saw  upon  a  steamboat 
my  aunt.  She  had  become  crazy  in  my  absence  and  was 
under  the  charge  of  keepers.  As  I  neared  the  boat  to 
speak  to  her  she  leaped  overboard  and  was  drowned,  and 
her  body,  with  a  fearful  idiotic  leer  upon  her  face,  floated 
past  me  so  close  that  I  could  touch  it.  I  awoke  with  a 
sudden  start,  trembling  from  head  to  foot ;  and,  although 

6- 


66  NER  VO  US  DISEASES. 

in  a  moment  I  realized  that  it  was  but  a  dream,  yet  the 
feeling  of  terror,  instead  of  leaving  me,  rather  increased. 
I  was  obliged  to  rise,  light  the  gas,  and  leave  the  room  and 
remain  for  several  hours  in  an  adjoining  one.  I  then  re- 
turned to  bed  and  slept  until  morning  ;  but  the  next  even- 
ing, when  it  came  time  to  retire,  the  recollections  of  the 
past  night  were  so  vivid,  and  the  intensity  of  the  mental 
suffering  so  clearly  before  my  mind,  that  I  could  not  force 
myself  to  retire.  ^ly  reason  told  me  that  this  Avas  a 
foolish  feeling,  and  that  I  ought  to  conquer  it ;  but  after 
a  severe  struggle  reason  gave  place  to  this  undefinable 
feeling  of  terror.  That  night,  and  for  several  nights  after- 
ward, although  I  was  not  addicted  to  drinking,  I  drank 
strong  liquor  until  my  senses  were  clouded,  and  this  I  did 
intentionally,  otherwise  I  could  not  have  retired. 

'*  Daring  the  daytime,  when  thinking  over  this  fearful 
attack,  I  concluded  that  if  it  were  given  me  to  choose  be- 
tween passing  one  such  night  and  being  deaf,  blind,  or  lame 
for  life,  I  should  choose  the  latter ;  nay,  I  felt  that  even 
death  itself  would  be  preferable  to  such  another  night.  I 
have  never  since  experienced  such  intense  suffering,  but 
have  passed  through  it  many  times  in  lighter  forms. 

"This  fall  (1875)  it  took  a  different  turn.  Upon  re- 
tiring I  was  unable  to  keep  my  eyes  closed,  because  the 
moment  I  closed  them  a  feeling  akin  to  fright  would  cause 
me  to  open  them. 

"This  was  like,  but  incomparably  less  than,  the  dream- 
evolved  terror.  Nevertheless,  it  was  bad  enough.  It  did 
not  come  if,  sitting  up,  I  closed  my  eyes ;  but  to  lie  down 
and  close  them  was  often  enough ;  or,  if  the  emotion  did 
not  then  arise,  it  seemed  to  burst  upon  me  just  as  I  was 
conscious  that  sleep  was  near.  These  attacks  were  the 
Avorst.  I  was  afraid — and  of  nothing.  No  reasoning 
helped  me.  As  I  am  by  nature,  despite  my  professional 
life,  hardy  and  courageous,  I  was  rather  ashamed  of  being 


SOME  DISORDERS  OF  SLEEP.  67 

fearful  of  nothing,  knowing  that  in  battle  I  had  had  no 
more  fear  than  others,  and  none  that  disturbed  me. 

''After  tossing  endlessly  for  hours  I  would  at  last  sleep 
for  an  hour  or  more  with  the  sense  of  sleeping  ill.  If  1 
had  a  bad  bout,  I  sometimes  awakened  with  my  mind  not 
clear  and  feeling  as  if  I  needed  effort  to  steady  it." 

Despite  these  alarming  symptoms  this  gentleman  got 
well  after  a  summer  in  camp  in  Maine. 

Others  have  described  to  me  this  state  of  fear  in  the 
prae-dormitial  condition.     Says  one: 

Case  XX. — ''I  have  had,  like  others,  nightmare;  but 
this  comes  over  me  while  I  am  quite  conscious,  and  of  this 
I  am  sure.  Whilst  yet  capable  of  mental  analysis  and  just 
pleasantly  drowsing,  I  simply  and  abruptly  realize  that  I 
am  afraid.  I  feel  it  coming.  I  am  not  paralyzed,  as  by 
nightmares ;  I  can  move.  If  I  fully  sit  up,  it  is  over ; 
but  if  I  delay  to  do  so,  and  it  catches  me,  it  stays  on  for 
a  minute  or  two  after  I  am  completely  awake  and  master 
of  myself.  I  sometimes  lie  still  with  open  eyes  and  seek 
to  know  why  I  fear,  or  reason  it  over,  but  nothing  relieves 
me.  The  fear  goes  by  degrees,  but  if  at  once  I  he  down 
again  and  close  my  eyes  it  comes  back." 

Another  mental  state,  somewhat  akin  to  this  last  (for 
fear  and  anxiety  are  near  akin),  also  occupies  the  prae- 
dormitium.  It  is  always  an  associate  of  bad  sleep  or  of 
insomnia,  and  consists  in  a  series  of  unreasonable  fears 
and  anxieties.  I  will  let  a  sufferer  tell  his  story  as  he 
wrote  it  for  me. 

Case  XXI. — This  sufferer  was  fifty  years  old,  of  ner- 
vous temperament,  a  man  of  restless  intelligence,  anxious 
always,  successful  past  the  common,  free  from  disease,  en- 
dowed with  a  perfect  stomach,  and  habitually  insomnic. 
He  called  three  hours  a  good  sleep,  and  for  years  lived  on 


68  NERVOUS  DISEASES. 

this  and  an  afternoon  nap  of  an  hour.  Now  and  then  his 
restlessness  got  worse,  and  was  the  insomnia  of  over-vigilant 
and  excited  centres,  which  furnished  a  succession  of  anx- 
ieties, each  in  turn  capable  of  inhibiting  sleep.  He  says : 
"  This  trouble  haunts  the  time  close  to  sleep.  I  lie 
down  ;  am  easy,  and  assured  of  sleep.  Suddenly,  I  think, 
is  the  gas  turned  off  properly  ?  I  get  up  and  look  ;  re- 
turn to  bed  ;  get  up  again,  and  so  on.  At  last  I  become 
anxious  as  to  my  son,  aged  six.  Is  he  safe  in  bed  ?  Will 
he  fall  out  ?  My  wife  goes  to  see,  reassures  me,  and  then 
I  go  myself,  and  go  a  dozen  times.  Next,  it  is  the  fur- 
nace, or  the  locks,  or  fear  of  fire,  until,  worn  out,  I  am 
surprised  by  sleep.  It  seems  as  if  this  thing  waits  for  me 
at  the  gates  of  sleep,  and  I  can  understand  that  just  then 
one's  fancies  may  run  wild.  But  once  awake,  the  thing 
goes  on  until  I  am  ashamed  of  the  demands  made  upon 
my  wife,  and,  too,  of  my  own  folly.  I  know  of  others 
who  have  the  same  trouble,  but  never  in  the  day  season." 

Sleep-numbness.  Nocturnal  Paresis  or  Paralysis. 
As  sleep-numbness,  this  disorder  has  become  familiar 
since  I  described  it  in  February,  1876,  and  later  more 
fully  in  my  book  in  1882.  Since  then,  Dr.  Andrew  H. 
Smith,  in  this  country,  and  Dr.  Saundby,  in  England, 
have  written  of  it  anew;  the  former  as  an  undescribed 
neurosis,  and  the  latter  without  full  knowledge  of  what 
had  already  been  written.  Dr.  Saundby  thinks  I  ap- 
pear to  have  recognized  this  condition,  but  is  of  the 
opinion  that  the  name  I  gave — nocturnal  hemiplegia 
— in  view  of  the  occasional  association  of  temporary 
loss  of  powder,  is  not  very  appropriate.  In  fact,  I  de- 
scribed pronounced  cases  chiefly,  and  their  duration  had 
nothing  to  do  with  the  nomenclature. 

In  general,  functional  day-numbness  (as  I  and  others 
have  described  it),  whether  neurotic,  anaemic,   gouty. 


SOME  DISORDERS  OF  SLEEP.  gg 

diabetic,  atonic,  or  asthenic,  is  apt  enough  to  repeat 
itself  at  night  in  sleep.  Bat  there  are  people  who  never 
hav^e  day-numbness,  and  who  are,  nevertheless,  liable 
to  awaken  with  this  interesting;  neurosis. 

Definitions  of  it  do  not  admit  of  sharp  boundaries. 
It  may  be  local,  transient,  a  slight  numb  feeling,  a  faint 
tingling  of  the  fingers,  of  a  leg,  or  of  one  side ;  or  else 
it  may  be  intense,  and  present  us  with  paresis  and  real 
defects  of  the  touch-  and  pain-sense.  In  another  case 
it  may  show  itself,  though  rarely,  as  an  alarming  mono- 
plegia, or  as  a  distinct  hemiplegia,  lasting  but  a  few 
moments,  or  growing  worse  during  hours.  Again,  it 
may  involve  the  whole  body,  but  is  then  apt  to  be  less 
severe  than  are  the  hemi-  or  monoplegic  forms.  I  have 
seen  several  of  them  in  one  person;  at  this  time  slight 
numbness,  and  at  that  hemiplegia,  alarmingly  positive, 
with  marked  loss  of  power  and  with  lessened  sensibility. 
For  Dr.  Andrew  A.  Smith,  waking-numbness  is  a 
parsesthesia  at  the  exit  from  sleep,  and  "  in  this,^'  he 
says,  ^^  there  is  nothing  added,  and  nothing  taken 
away.'^  But  these  subjective  states,  which  to-day  are 
mere  tingling  or  formication,  may  to-morrow  deepen 
into  the  semblance  of  hemiplegia,  with  distinct  loss  of 
sensation.  It  is  only  a  question  of  degree.  The  neur- 
asthenic, the  hysterical,  the  tobacco-poisoned,  the  gouty, 
the  dyspeptic,  are  liable  to  awaken  with  numbness, 
tingling,  dyssesthesia  of  a  part,  or  of  both  hands,  or  of 
a  side.  It  goes  off  in  a  few  minutes.  More  rarely 
there  is  a  distinct  weakness  of  an  arm  or  side,  with  dys- 
aesthesia,  very  rarely  with  complete  loss  of  feeling. 
And  so  it  is  that  we  may  have  various  degrees  of  dis- 
turbance from  faint  tingling  to  profound  temporary 
dyssesthesia,  and  defects  of  power  from  paresis  up  to 


70  ^ER  VO  US  DISEASES. 

a  brief  simulation  of  paralysis.  Were  the  worst  of 
these  simulations  to  last,  they  would  be  grave  enough, 
and,  in  fact,  it  does  sometimes  happen  that  such  states 
as  I  describe  may  ev^en  deepen  in  intensity  after  the 
patient  is  fully  awake.  In  some  patients  they  recur 
night  after  night,  attack  both  hands  or  both  sides  on 
successive  nights,  or  occur  at  intervals  for  years.  I 
may  add  that  I  have  sometimes  seen  this  symptom  in 
men  apparently  vigorous,  and  that  it  also  occurs,  now 
and  then,  in  those  who  have  multiple  cerebral  aneurisms 
or  endarteritis.  I  have  seen  it,  too,  over  and  over,  in 
convalescent  hemiplegics.  They  awaken  with  the  palsy 
worse,  a  functional  condition  being  for  a  time  added  to 
that  which  had  an  organic  cause,  or  the  sound  side 
suffers,  to  their  great  alarm. 

I  give  a  physician's  story  of  his  attack: 

"  Excessive  work,  with  double  abuse  of  tobacco  (smok- 
ing and  chewing),  had  caused  day-numbness,  which  troubled 
the  ulnar  territories  most.  One  morning  I  awakened  with 
transient  numbness  of  the  whole  left  hand,  with  no  true  loss 
of  touch.  A  week  later  I  had,  on  awakening,  dyssesthesia, 
with  pricking  of  the  whole  right  side,  including  face  and 
tongue.  I  arose,  found  leg  and  arm  weak,  examined  sen- 
sation in  the  finger-tips  and  recognized  the  fact  that  with 
scissor-points  applied  to  the  finger-cushions  I  could  not  be 
sure  of  them  as  two  at  one-third  of  an  inch  separation.  T 
was  about  to  send  for  a  physician,  when  the  sense  of  ting- 
ling becoming  worse  in  the  extremities,  the  dysiesthesia 
grew  less,  and  in  two  hours  I  was  as  well  as  ever." 

It  is  of  interest  that  he  soon  after  saw  a  case  of 
waking-numbness  in  a  tobacco-using  patient,  wdiom  he 
confidently  reassured,  stating  his  own  case.      In  fact. 


SOME  DISORDERS  OF  SLEEP.  71 

however,  the  patient  owed  his  numbness  to  unrecognized 
diabetes,  and  it  ended  in  gangrene. 

The  history  of  numbness  in  all  its  grades  points  to  a 
central  origin,  but  that  it  may  arise  otherwise  is  also 
clear.  In  some  cases  of  neuritis  I  have  seen  night- 
numbness  as  a  first,  a  transient,  and  a  repeated  symp- 
tom preceding  the  pain  by  several  days. 

Some  years  ago,  whilst  writing  my  book  on  Nerve 
Lesions,  I  froze  my  right  ulnar  nerve  at  the  elbow  with 
alcohol  at  0°  F.  For  ten  days  afterward  I  had  more 
or  less  discomfort,  and  at  times  acute  pain,  but  espe- 
cially, on  several  occasions,  a  positive  numbness  of  the 
ulnar  territory  with  which  I  awakened.  It  passed  off 
with  friction  in  an  hour,  but  was  much  worse  than  the 
occasional  day-numbness  which  my  somewhat  rash  ex- 
periment created.  Yet,  for  a  time,  it  was  purely  a 
waking  symptom  and  faded  swiftly.  The  more  pro- 
found examples  of  hemiansesthesia  with  paresis  as  post- 
somnic  states  are,  I  think,  most  apt  to  involve  the  right 
hemisphere.  I  recall  no  instance  of  aphasic  accompa- 
niments in  the  rarer  left  brain  disturbances.  In  their 
varieties  these  symptoms  probably  represent  functional 
irritations  or  inhibitions  of  quite  various  parts  of  the 
brain  ;  unlike  their  hysteric  related  states,  they  are  felt 
in  the  face  as  well  as  below  it,  and  are  clinically  of  kin 
to  the  functional  anaesthesias  and  pareses  of  certain 
migraines. 

In  some  cases,  notably  in  hysteria,  waking-numbness 
is  associated  with  pain  in  the  parts  affected,  or  there 
are  also  parsesthetic  expressions,  as  sense  of  constriction, 
of  elongation,  or  of  enlargement  of  limbs,  etc.  At 
times  the  sensation  resembles  the  furious  formication 
of  aconite-poisoning. 


72  ^^R  VO  US  DISEASES. 

In  Dr.  Ormerod's  paper^  on  numbness  (which  is  the 
best  of  the  English  essays)  he  speaks  of  the  pain  suffered 
by  some  of  his  cases^  and  as  to  this  he  is  quite  correct. 
In  fact,  there  are  those  who  awake  with  pain  in  arm  or 
leg,  or  both,  so  intense  as  to  make  the  accompanying 
numbness  seem  of  little  moment.  Pain  as  an  accompa- 
niment is  also  mentioned  by  Sinkler,  but  not  as  being 
severe;  whereas  it  is  in  some  instances  of  waking- 
numbness  very  great.  I  add  two  or  three  cases.  The 
first,  again  that  of  a  physician,  I  give  as  he  wrote  it. 
He  says: 

"  The  preparative  causes  of  my  present  state  were  excess 
in  tobacco  and  a  practice  Avhich  left  me  no  rest.  Then 
came  a  domestic  calamity,  and  I  broke  down  with  distress 
in  the  occiput  and  an  amount  of  suddenly  developed 
physical  feebleness  which  annoyed  me.  I  could  not  walk 
up  three  flights  of  stairs  without  resting.  My  heart  be- 
came rapid — 90  to  100  ;  my  temperature  97.4°,  and  at 
night  98°.  I  ^Yas  struck,  too,  with  the  weakness  of  my 
bladder,  the  urine  merely  falling  as  it  emerged.  All  this 
was  in  December.  In  February  I  began  to  have  night- 
numbness,  and  woidd  wake  in  the  night  with  all  four 
limbs  numb.  The  worse  attacks  were  those  at  waking  in 
the  morning  late.  Early  in  the  night  the  symptoms  were 
less  notable,  or  else  affected  one  limb  only,  or  one  side.  At 
times  it  was  mere  tingling ;  at  others,  positive  lessening  of 
sensibility  to  touch  and  pain.  When  this  was  the  case  the 
limbs  were  for  a  time  paretic ;  on  one  occasion  so  much  so 
that  I  fell  on  getting  out  of  bed.  The  trouble  has  never 
lasted  more  than  thirty  minutes,  and  usually  went  off  with 
great  tingling,  as  of  a  limb  asleep,  as  is  said.  After 
March  I  began  at  times  to  have  numbness  in  daytime, 
but  rarely  so  intense  as  to  disturb  feeling.     The  tingling 

1  SI.  Bartholomew's  Hospital  Reports,  1S«3. 


SOME  BISOBDERS  OF  SLEEP.  73 

occasionally  affected  my  whole  surface,  and  was  apt  to 
begin  around  the  mouth." 

In  this  case  the  symptoms  were  neurasthenic,  and 
absolutely  no  other  cause  could  be  assigned  for  them. 
Recovery  was  complete.  The  next  cases  are  from  Dr. 
Fere/  and  are  certainly  hysterical  and  of  great  interest. 

Case  XXII. — ''Mrs.  V.  came  to  consult  me,  for  the 
first  time,  at  the  Saltpetriere  on  January  12,  1885.  She 
was  accompanied  by  her  mother,  who  was  over  sixty  years 
of  age,  but  still  very  agile,  and  looked  much  younger 
than  she  really  was.  The  mother  had  a  painful  ovarian 
spot  with  slight  anaesthesia  on  the  left  side.  Although 
the  menses  had  ceased  nine  years  previously,  she  had 
been  subject  to  migraine,  with  attacks  of  melancholia,  and 
occasionally  convulsive  fits.  The  father,  who  had  been  a 
drunkard  and  profligate,  had  quitted  the  house  twenty 
years  before,  and  no  one  knew  what  had  become  of  him. 
A  brother  of  the  father  had  died  iu  prison  while  under- 
going confinement  for  swindling.  Mrs.  V.  had  two  sisters 
born  after  her.  The  one  had  died  of  convulsions  connected 
with  teething  at  the  age  of  eighteen  months  ;  the  other  died 
of  convulsions  when  only  six  months  old. 

"  Mrs.  V.  had  been  a  precocious  child  both  physically 
and  mentally.  She  had  Avalked  and  spoken  at  a  very  early 
age,  and  had  learned  very  rapidly  at  school.  She  has  never 
had  convulsions  nor  tic,  but  from  the  age  of  six  has  suf- 
fered from  frequent  migraine,  followed  by  vomiting,  and 
during  her  whole  life  her  sleep  has  been  troubled  by  noc- 
turnal terrors  and  nightmare.  Menses  began  when  she 
was  twelve.  At  the  age  of  seventeen  she  had  attacks  of 
chorea  in  consequence  of  worry.  This  lasted  three  months, 
and  chiefly  affected  the  left  side.  At  nineteen  she  was  mar- 
ried, and  had  her  first  child,  a  boy,  when  twenty-three. 

1  Brain,  October,  1889. 
7 


74  NEB  VO  US  DISEASES. 

This  child  died  of  convulsions  on  the  eighth  day.  In  the 
following  year  she  was  delivered  of  a  child  stillborn. 
During  her  pregnancy  she  had  anorexia  and  vomiting, 
which  ceased  spontaneously  in  the  fourth  month. 

"Since  her  chorea  Mrs.  V.  has  always  enjoyed  good 
health,  and  has  had  no  distinctive  nervous  outbreaks  until 
about  three  years  ago.  At  the  time  her  husband  died  she 
suffered  severe  pecuniary  loss.  This  induced  insomnia, 
followed  by  loss  of  appetite  and  emaciation.  By  hard 
work  her  health  became  pretty  good.  About  two  months 
ago  she  had  a  very  abundant  metrorrhagia.  A  few  days 
after  this  mishap  she  began  to  feel  constrictive  pains  in 
the  head,  extending  over  the  whole  of  the  cranium,  but  pre- 
dominating in  the  postero-inferior  region,  which  appeared, 
moreover,  to  be  the  seat  of  a  constant  pressure.  From 
time  to  time  she  heard  a  cracking  noise  in  the  back  part 
of  the  neck,  Avhich  resounded  in  the  occipital  region  of  the 
skull.  At  nightfall  she  was  seized  by  painful  fancies,  of 
ruin  for  her  mother  and  her  daughter,  of  illness  for  all 
her  friends ;  at  the  same  time  she  was  a  prey  to  unusual 
pusillanimity  and  indecision.  Her  sleep  was  disturbed  by 
dreadful  nightmares.  She  was  widely  awake  toward  six 
in  the  morning,  but  was  incapable  of  making  any  move- 
ment. She  suffered  from  distention  of  the  bladder,  but 
could  not  even  think  of  getting  up.  Her  limbs  seemed 
numb  to  her,  and  as  if  wrapped  in  cotton.  She  appeared 
to  know  the  position  of  her  extremities  only,  and  it  seemed 
to  her  as  if  the  greater  part  of  each  limb  was  wanting, 
and  her  hands  and  feet  had  been  brought  up  close  to  her 
body.  The  sensation  is  analogous  to  that  experienced  by 
amputated  persons,  who  say  they  feel  only  the  extremity 
of  the  absent  limb.  She  could  make  no  movement  what- 
ever. "When  daylight  was  admitted  a  sensation  of  numb- 
ness and  pricking  gradually  appeared  in  the  extremities  of 
the  fingers  and  toes.     These  sensations,  occasionally  very 


SOME  DISORDERS  OF  SLEEP.  75 

painful,  preceded  the  return  of  ability  to  move.  About 
eight  o'clock  the  patient  could  get  out  of  bed,  maintain 
herself  in  a  standing  position,  and  make  movements  of  the 
arms.  The  complicated  movements  of  the  fingers,  how- 
ever, remained  almost  impossible.  She  was  thus  incapable 
of  fastening  her  clothes  or  of  taking  up  a  pin.  When  she 
had  moved  her  arms  and  had  been  rubbed  a  little  her  fin- 
gers became  more  supple.  From  the  time  she  awoke  until 
the  nearly  complete  restoration  of  movement  took  in  gen- 
eral about  three  hours.  One  day,  when  left  in  a  dark 
room  until  about  ten  o'clock,  she  was  found  in  the  same 
helpless  condition.  Movements  of  the  head  and  neck  and 
of  articulation  were  not  affected.  On  examination  no 
modification  of  the  external  aspect  of  the  limbs  could  be 
determined.  She  suffered  pain  in  the  region  of  the  left 
ovary  and  had  slight  anaesthesia  on  the  same  side.  The 
contraction  of  the  field  of  vision  was  tolerably  extensive, 
and  the  patient  was  insensible  to  violet  rays  in  the  left  eye. 
The  iris  of  the  left  eye  was  of  a  deeper  brown  and  the  pupil 
not  so  large  as  on  the  other  side.  Under  the  influence  of 
bitters,  iron,  bromide  of  potassium,  and  hydrotherapy 
combined  with  static  electricity  all  these  symptoms  dis- 
appeared in  the  space  of  three  weeks,  with  the  exception 
of  pain  over  the  ovary  and  the  hemiansesthesia.  This  case 
was,  of  course,  distinctly  hysterical." 

Case  XXIII. — Mrs.  P.  She  complained  of  sudden  shocks 
in  the  head  which  awoke  her  abruptly.  These  occurred 
by  night  four  or  five  times.  Finally  came  other  troubles 
which  raised  her  inquietude  to  a  climax.  When  her  sleep 
became  broken,  toward  four  or  five  o'clock  in  the  morning, 
she  found  that  she  could  not  move  any  of  her  limbs.  This 
general  helplessness  did  not  last  very  long,  for  after  a  few 
minutes  of  effort  she  recovered  power  of  movement  in  her 
right  hand  and  foot,  but  for  the  limbs  on  the  left  side 
prolonged  friction  was  necessary.     This  paresis  was  accom- 


76  NER  VO  US  DISEASES. 

panied  chiefly  ou  the  left  side  by  a  sensation  of  painful 
numbness  and  pricking.  The  hand  especially  was  cold, 
and  the  fingers  appeared  to  diminish  in  volume,  the  riugs 
hanging  quite  loosely. 

This  helplessness,  which  at  first  persisted  only  a  few 
minutes,  was  in  a  month's  time  prolonged  for  an  hour  or 
more.  The  patient  could  not  raise  herself  out  of  bed 
until  some  one  had  rubbed  her  energetically.  Even  then 
she  would  remain  for  many  hours  incapable  of  making 
any  delicate  movements  or  even  of  simply  fastening  her 
dress.  When  the  paralysis  was  at  its  maximum  the  patient 
declared  that  she  was  no  longer  conscious  of  the  existence 
of  her  own  body ;  that  she  was,  to  use  her  own  words,  a 
pur  esprit. 

Under  the  influence  of  cold  douches  repeated  twice  a 
day  at  regular  hours  and  a  tonic  treatment  of  iron,  nux 
vomica,  and  arsenic,  with  bromide  of  potassium  given 
every  evening  in  moderate  doses — one  to  three  grammes — 
her  condition  rapidly  improved.  The  paralytic  numb- 
ness on  waking  diminished  at  once  in  duration  and  then 
in  intensity.  At  the  end  of  fifteen  days  it  had  almost 
completely  vanished.  The  sensations  of  shocks  in  the 
head,  which  had  caused  the  patient  to  awake,  disappeared 
in  turn.  The  anorexia  and  pains  resisted  longer  ;  at  the 
end  of  six  weeks  the  pain  in  the  tendo-Achillis  still  per- 
sisted, but  in  time  it  too  disappeared. 

It  is  verv  clear  that  a  vast  rano;e  of  disease  or  dis- 
order  seems  capable  of  causing  night-palsy  in  its  variety 
of  degree.  As  concerns  the  cause^  there  is  much  differ- 
ence of  opinion;  some  look  upon  it  as  due  to  rare 
somnic  conditions  of  the  vessels  of  the  brain,  wdiile 
others,  like  Fere/  attribute  it  to  a  deficiency  of 
physiological  excitation — ^^  paralysis  from  irritation. ^^ 

1  Brain,  October,  1889. 


S03fE  DISORDERS  OF  SLEEP.  77 

Reflex  it  surely  is  at  times,  and  purely  local  or  periph- 
eral but  rarely. 

It  is  needless  to  discuss  treatment.  It  means  any- 
thing from  the  treatment  of  neurosis  to  that  of  gout, 
neurasthenia,  habits,  renal  insufficiency,  diabetes,  and 
what  not. 

Sleep-ptosis.  Another  form  of  annoyance  to  which 
I  have  time  to  give  but  a  passing  notice  is  the  ptosis 
of  sleep.  Of  this  I  nowhere  find  mention.  The  pa- 
tient awakens  with  palsied  lips;  lifted,  they  fall.  In 
some  instances  it  lasts  a  few  minutes  or  longer,  or  else 
before  the  disorder  repairs  itself  sleep  returns,  and  in 
the  morning  the  patient  has  it  anew,  or  awakens  with- 
out it. 

I  append  two  cases  which  came  under  the  care  of 
Dr.  de  Schweinitz: 

Case  XXIV. — One  was  that  of  a  woman,  aged  sixty-five 
years,  as  I  understand  in  good  health  and  not  hysterical. 
There  was  some  irritation  of  the  lids  and  slight  general  con- 
junctivitis, also  there  was  a  slowly  ripening  double  cataract. 
As  the  vision  was  still  fairly  good  she  read  much,  and  if  she 
used  her  eyes  freely  in  the  evening  was  sure  to  experience 
the  following  trouble  :  waking  in  the  night,  she  found  that 
her  eyes  could  not  be  opened  by  the  will.  After  they  were 
forcibly  opened  they  remained  controllable  by  volition 
until  after  sleeping  again,  when  the  same  phenomena 
recurred. 

The  notes  are  not  complete,  and  although  she  describes 
the  ptosis  as  spastic,  it  seems  to  me  to  have  been  only 
a  night-palsy  of  temporary  duration.  A  somewhat 
similar  case  was  observed  at  my  clinic  a  few  weeks 
ago,  and  I  have  seen  a  number  of  them. 


78  NER  VO  US  DISEASES. 

Case  XXV. — J.  C,  aged  twenty-nine  years,  a  widow, 
was  in  absolute  health  after  a  childless  marriage  of  four 
years.  Soon  after  her  husband's  death  she  began  to  suffer 
with  sexual  dreams,  and  later  with  these  and  hemianses- 
thesia  of  decisive  type  without  loss  of  power.  A  year  from 
the  beginning  of  her  widowhood  she  awakened  thrice  in 
one  night  with  paralysis  of  the  lids.  There  were  no  eye- 
troubles,  but  the  lids  as  she  awakened  could  not  be  lifted 
at  will.  When  raised  by  a  finger  they  fell  flaccid,  and 
only  by  degrees,  in  an  hour,  recovered  tone.  This  trouble, 
unknown  to  the  day,  continued  for  many  months,  and, 
indeed,  disappeared  only  when  this  and  all  other  symptoms 
were  promptly  dispersed  by  a  second  marriage. 

lu  another  case  the  ptosis  was  like  the  emotional 
spastic  ptosis  of  hysteria  we  see  in  waking  hours,  and 
well  know^n  to  neurologists: 

Case  XXYI. — A  woman,  aged  sixty-seven  years,  in  good 
general  health,  but  full  of  notions ;  for  fourteen  years  she 
has  been  the  subject  of  stubborn  retinal  asthenopia ;  the 
eye-grounds  are,  however,  healthy  ;  there  is  a  considerable 
degree  of  hypermetropia  and  astigmatism,  together  with  in- 
sufiiciency  of  the  internal  straight  muscles.  Each  night, 
for  a  long  time,  usually  between  twelve  and  two,  she  has 
been  awakened  over  and  over  by  a  feeling  that  her  eyes 
have  closed  spasmodically.  She  arises,  forces  them  open 
with  difficulty,  and  bathes  them,  ' '  because  the  lids  feel  as 
if  they  were  sticky  and  would  glue  fast."  The  phenomena 
repeat  themselves,  but  never  by  day. 

This  case  proved,  I  believe,  very  obstinate,  and  is 
only  notable  because  it  is  of  nocturnal  origin  alone. 

Sleep-pain.  I  add  a  feW'  Avords  as  to  what  is,  for 
rarity,  a  medical  curiosity.  I  find  in  my  note-book 
some  half-dozen  cases  of  pain  in  the  legs,  never  known 


SOME  DISORDERS  OF  SLEEP.  79 

to  the  day,  and  needing  sleep  as  a  conditioning  factor. 
Whenever  I  have  spoken  of  this  obscure  disorder  to 
a  patient  he  is  apt,  if  intelligent,  to  say :  ' '  No,  not 
pain;  it  is  distress.'^  It  occurs  in  middle  life,  or  later, 
and,  without  previous  disease,  comes  on  slowly.  In 
one  case  it  followed  typhoid  fever.  The  cases  are 
alike.  A  man  is  well  in  the  day;  walks,  works,  does 
as  do  others.  Some  time  after  he  falls  asleep  he  is 
awakened  by  aching  in  the  legs,  from  the  sole  half-way 
to  the  knees.  There  is  but  one  remedy — motion.  He 
rises,  walks  for  ten  minutes,  is  eased,  goes  to  sleep,  and 
in  an  hour  or  two  awakens  to  feel  the  distress  and  repeat 
the  relieving  exercise.  There  is  no  unusual  heat  or 
cold;  nor  any  abnormal  appearance.  The  matter  is 
unpleasantly  simple,  and  there  is  no  clue  to  a  cause. 

The  case  I  now  quote  from  my  note-book  I  saw  two 
years  ago.     It  is  typical  of  a  rare  condition. 

Case  XXVII. — J.  C,  aged  fifty-eight  years,  farmer, 
Kentucky ;  married,  two  healthy  children ;  himself  of 
sound  breed.  Has  worked  hard  and  has  never  known  a 
serious  illness.  Xo  malaria.  In  October,  1886,  consulted 
me.  I  found  him  a  man  weighing  180  pounds ;  height  six 
feet,  vigorous,  Avith  soft  arteries  ;  heart  beating  76  and  per- 
fect. He  has  no  piles,  hernia,  or  varicose  veins.  Eats  well ; 
is  in  all  ways  moderate  and  regular ;  does  not  smoke  and 
does  not  chew  tobacco.  All  the  reflexes  are  normal ;  the 
heart  and  arterial  tension  healthy.  Xo  organ  is  diseased  ; 
can  work  all  day ;  no  tenderness  in  nerve-tracts. 

About  four  years  ago  he  began  to  Avake  now  and  then 
with  distress  in  the  legs.  During  the  next  year  this  got 
worse,  and  now  is  a  source  of  extreme  suffering  and  of 
disabihty,  because  of  the  loss  of  sleep  it  causes.  Within 
an  hour  after  bedtime  he  awakens  in  Avhat  he  calls  tor- 


80  NER  VO  US  DISEASES. 

meut.  From  the  knee  to  the  toe  his  legs  ache,  without 
throb  or  sharp  pain.  He  rises,  walks  until  weary,  goes  to 
bed,  sleeps,  and  wakes  to  the  same  pain  or  distress.  Again 
walks,  and  so  on,  until  day  brings  relief. 

At  the  Infirmary  we  learned  that  in  the  attacks  the 
legs  remain  normal  as  to  temperature,  reflexes,  and  elec- 
trical conditions,  as  well  as  to  sensation.  No  remedies 
were  of  the  least  use,  except  morphine,  and  I  advised  its 
steady  use  in  despair  as  to  other  means. 

Sensory  Shocks.  Another  phenomenon  of  sleep, 
or  its  borders,  and  also  in  the  sensory  sphere,  I  described 
long  ago  as  sensory  shock  or  discharge.^  This  is  a  more 
rare,  but  also  a  more  interesting  disorder,  than  numb- 
ness. Except  my  own  paper  and  a  small  book  by  a 
homoeopathic  practitioner,^  I  know  of  no  literature  on 
the  subject  beyond  a  few  lines  of  remark  on  my  paper 
in  an  essay  of  Hughliugs  Jacksou's.  Nevertheless,  the 
subject  is  still  of  interest. 

All  the  disturbing  phenomena  of  sleep  at  some  time 
represent  themselves,  more  or  less  well,  in  our  waking 
hours  ;  but  sensory  shocks  are,  of  all  disorders  of 
sleep,  the  most  rare  in  daytime. 

In  the  pn^-dormitium  while  sensation  is  fading,  but 
never  on  waking  from  sleep,  the  patient  has  in  his  head 
a  sudden  and  violent  sensation,  and  the  forms  it  assumes 
may  be  classified  thus: 

1.  In  the  sphere  of  general  sensation.  He  feels  as  if 
struck,  or  as  if  he  had  a  shock  like  that  which  a  sudden 
arrest  of  motion  causes ;  or  it  is  a  feeling  of  i^ending. 


1  Virginia  Medical  Journal,  op.  cit.    Lectures  on  Nervous  Diseases,  op.  cit. 

2  In  Dr.  W.  S.  Searle's  book  he  described  sleep-shocks  as  a  neurosis,  hitherto 
unmentioned  in  medicine,  and  was  evidently  unaware  that  I  had  already  and 
fully  delineated  its  peculiarities. 


SOME  DISORDERS  OF  SLEEP.  81 

or  as  of  a  bolt  driven  through  the  head.     These  are  the 
most  comiQOii. 

2.  Auditory.  A  loud  noise,  like  that  of  a  pistolshot 
or  of  the  crash  of  broken  glass,  or  as  of  a  bell,  or  a  wire 
sharply  twanged. 

3.  Visual.     A  flash  of  light. 

4.  Olfactory.     Sudden  sense  of  an  odor. 

5.  I  doubtfully  add  what  I  call  emotional  discharges. 
These  are  always  mere  abrupt  sensations  of  fear,  some- 
times preceding  the  sensory  shock,  and  sometimes  fol- 
lowing. 

What  happens  is  usually  this:  A  man  going  to  sleep, 
but  still  quite  conscious,  and  able  to  observe,  feels  sud- 
denly a  shock  in  the  head.  It  seems  mechanical,  as  of 
a  blow,  or  noise,  or  else  of  both  ;  and,  also,  there  may 
be  added  a  flash  of  light,  vivid  or  like  the  soft  summer 
lightning  along  an  evening  horizon.  The  intensity  of 
these  phenomena  may  be  appalling,  and  even  those  who 
are  used  to  them  greatly  dread  their  return.  The  first 
experience  is  sometimes  most  alarming. 

In  many  cases  there  is  an  aura.  A  physician,  who 
came  to  me  on  account  of  these  attacks,  first  called  my 
attention  to  this.  While  waiting  for  sleep  he  became 
aware  of  an  indescribable  something  w^iicli  rose  from 
the  feet  and  hands,  and,  taking  eight  or  ten  seconds  to 
reach  the  head,  ended  in  a  sound  like  the  crash  of  glass 
houses  breaking  in  a  hail-storm,  witli  a  vivid  flash  of 
yellow  light,  leaving  him  for  a  moment  dazed,  but  able 
at  once  to  rise,  or  to  think.  Such  is  the  usual  account 
given  of  this  aura.  It  never  varies,  save  that  it  may 
rise  only  from  the  belly. 

All  sufferers,  or  nearly  all,  who  have  an  aura,  say 
they  can  stop  the  attack  by  turning  over,  or  sitting  up, 


82  NER  VO  US  DISEASES. 

or  even  by  opening  the  eyes.     A  friend^  who  had  this 
trouble  owing  to  tobacco,  says  : 

Case  XXVIII. — "The  shocks  were  of  two  kinds;  one  as 
if  I  received  in  the  brain  a  thump,  and  one  as  if  a  pistol- 
shot  occurred  in  the  head.  I  had  for  a  long  while  no  idea 
that  the  pleasant  mistress,  Xicotia,  was  disturbing  my  in- 
ternal economy.  At  last,  before  learning  this,  I  got  used 
to  these  abnormal  things,  and  would  lie  still  and  feel  what 
you  call  the  aura.  By  the  way,  it  is  not  at  all  like  an  air, 
but  like  the  surging  upward  of  something  more  positive. 
When  it  gets  to  the  neck  I  am  gone ;  the  explosion  occurs. 
Below  that  I  can  avert  the  wretched  thing,  either  by  rising 
or  rolling  over,  for  it  never  comes  except  I  be  on  my  right 
side.     IS'o  mental  effort  suffices  to  check  it." 

I  have  notes  of  two  males  wdio  suffer  only  if  on  the 
right  side,  but  I  have  not  always  made  inquiry  as  to 
this  point. 

The  aura  is  said  at  times  to  be  like  a  tingling,  or  else 
is  described  as  an  upward  surge  of  indescribable  nature, 
and  at  times  rises  only  from  the  epigastrium.  Often 
there  is  none.  Once  felt  in  any  case,  it  usually  con- 
tinues in  some  form  to  precede  all  future  attacks. 

There  is  another  form  of  Avarning,  Avhich  patients 
only  succeed  in  describing  as  a  state  of  brain  which 
foretells  the  shock.  I  have  heard  this  called  a  hum- 
ming, or  buzzing,  within  the  head. 

Hysterical  women  are  often  quite  unable  to  stop  the 
shocks,  or  else  the  aura  is  too  swift  to  be  a  timely  warn- 
ing. It  is  rare  to  find  any  grave  result.  A  few  people 
become  vertiginous,  but  not  severely,  x^t  first,  alarm 
causes  emotional  scare  and  a  quickened  heart,  and  in 
some  few,  even  when  repetition  has  lessened  the  terror 
of  the  shocks,  they  cause  a  more  prolonged  palpitation 


SOME  DISORDERS  OF  SLEEP.  83 

of  the  heart.  In  a  few  minutes,  when  sleep  is  again 
near,  comes  another  shock,  or  there  are  a  number  of 
slight  attacks,  as  of  a  bell,  or  a  guitar-string  twanged, 
and  by  degrees  fading  away ;  visual  discharges  less 
commonly  recur  in  this  manner. 

I  have  over  and  over  met  with  cases  of  sensory  shock 
in  the  daytime,  but  only  in  the  hysterical.  In  some 
few  people  they  occur  during  sleep,  and  awaken  the 
patient,  but  their  habitual  time  is  in  the  prse-dormitium. 

All  of  these  curious  outbreaks  represent,  as  a  rule,  the 
^^  coarse  stuff  ^'  of  sensory  product,  or  something  near 
it.  There  is  sense  of  shock  alone,  or  this  in  succession 
with  noise  or  light,  or  both.  The  noise  is  more  rarely 
comparable  as  to  a  note  of  music,  or  as  to  a  bell,  or  a 
string  vibrating.  And  so  also  of  the  optic  explosion. 
There  is  light,  violet  or  pale  yellow.  Xo  visions  appear; 
no  voice  calls.  It  is  ^^  primary  sensory  stuff,^'  and 
no  more.  In  the  one  case  connected  with  smell  the 
patient  had  an  epigastric  aura,  and  smelt  bananas.  She 
had  anosmia. 

These  singular  symptoms  are  found  in  some  neuras- 
thenics, in  hysteria,  and  most  often  in  men  as  a  result 
of  overuse  of  tobacco-smoking.  I  first  knew  of  it  in 
my  own  case,  during  an  attack  of  neurasthenia,  many 
years  ago,  and  soon  learned  that  it  was  immediately  due 
to  my  segar.  I  can  assure  you  that  one's  first  acquaint- 
ance with  it  is  most  terrifying.  Bromides  and  strych- 
nine control  it,  as  I  have  elsewhere  stated. 

I  pointed  out  years  ago  the  interesting  resemblance 
of  these  innocent  attacks  to  epilepsy,  and  Hughlings 
Jackson  has  also  noted  the  fact.     Bennett,^  in  a  paper 

1  Lancet,  April,  1889. 


84  ^"ER  VO  US  DISEASES. 

on  the  Sensory  Auras  of  Epilepsy,  describes  cases  in 
which  the  signal-aura  consisted  simply  of  crude  sen- 
sation, such  as  tingling  or  pain,  which  he  calls  sensory 
epilepsy.  These  are  sensory  cortex  centre  explosions, 
with  consciousness  and  without  spasm. 

Xext  to  touch-aura  in  epilepsy  comes  most  often  optic 
aura — sense  of  light,  or  definite  color  with  form.  In 
the  prse-dormitium  explosions  the  visual  phenomena  are 
still  more  crude  than  in  these ;  but  in  epilepsy  audi- 
tory auras  are  rare,  and  gustatory  and  olfactory  auras 
still  more  uncommou.  The  patient  who  has  a  special 
sensory  aura  feels  as  if  j? truck  a  sharp  blow,  or  per- 
ceives a  noise  in  the  head,  or  sees  red  fire,  or  a 
flash  of  light,  and  has  no  fit.  Or  else  he  has  a  sub- 
jective taste,  or,  like  a  physician  I  know,  smells 
human  ordure  for  half  an  hour,  and  may  or  may  not 
fail  to  have  the  usual  sequent  spasms.  These  epilep- 
sies are  very  like  such  prsesomnic  shocks  as  give  us 
in  their  completest  form  a  sense  of  tingling,  which, 
rising,  ends  in  a  more  abrupt  sensory  discharge,  as  of 
a  sensation  of  shock,  light,  or  sound,  or  these  variously 
combined,  as  does  also  occur  in  epilepsy  sometimes,  as 
I  have  seen.  Agaiu,  too,  in  the  subjects  of  sleep-shocks 
are  found  those  who  have  in  the  prsesomnic  state  condi- 
tions of  terror  or  daze,  which  are  brief,  and  represent 
like  phenomena  in  the  intellectual  or  emotional  sphere, 
such  as  are  the  dazed  or  dreaming  states  of  some  epilep- 
tics. And,  curiously  enough,  this,  too,  may  in  our  illus- 
trative shocks  be  preceded  by  a  sensory  aura  of  one  or 
two  senses — double  auras. 

In  epilepsy  with  auras  we  may  have,  first,  an  aura — 
i.e.,  a  sensory  discharge,  usually  simple  tingling — and 
then  a  sense  of  flash  or  sound,  or  of  light  and  sound 


SOME  DISORDERS  OF  SLEEP.  85 

together;  the  centres  being,  one  may  notice,  in  juxta- 
position.^ 

In  prsesomnic  discharges  the  discharge  is  simple,  or 
preceded  by  tingling — true  aura — vague  epigastric  sen- 
sations. The  analogy  to  epilepsy  is  closer  when,  as 
often  occurs,  an  uncontrollable  jerk  or  flop  of  the  whole 
body  ends  the  attack.  With  motor  centres  patholog- 
ically over-excited,  or  capable  of  being  morbidly  over- 
charged, widespread  epileptic  motor  phenomena  may 
follow  the  sensory  discharges,  and  in  early  cases  of  sen- 
sory explosions  hysterical  convulsions  of  mild  type  may 
result,  and  thus  bring  us  still  more  near  to  the  sequen- 
tial chain  of  epileptic  conditions.  On  the  other  hand, 
epilepsy  is  not  a  disorder  which  haunts  the  praesomnic 
time.  However  close  the  apparent  analogy,  there  must 
be  a  wide  difference  between  it  and  these  sensory  explo- 
sions. 

Lastly,  there  is  a  form,  which  I  have  seen  but  twice, 
in  which  we  have  an  aura — a  flash,  shock,  or  sound — 
and  a  sense  of  pain  darting  down  the  cervical  spine 
and  then  along  both  arms  to  the  finger-ends. 

Sleep-jerks.  Chorea.  In  the  motor  sphere  are 
certain  disorders  which  trouble  the  sleep,  or  praesomnic 
state,  in  hysteria  and  neurasthenia,  and  which  are  only 
distinguished  from  phenomena  found  in  health  by  their 
excesses.  We  all  have  had  the  common  experience  of 
a  sudden  jerk  of  the  body  as  we  were  falling  asleep. 
This,  in  certain  cases,  is  exaggerated  as  to  degree  and 
number,  and  may  occur  also  during  sleep.  I  have  seen 
many  cases  in  which,  scores  of  times  in  each  night, 
the  sleeper  was  awakened  by  a  violent  movement  of 
every  muscle  at  once.     In  others  the  jerks  are  of  arms 

1  Angular  gyrus  and  superior  tempor  o-sphenoidal  convolution. 

8 


86  ^V^^  VO  US  DISEASES. 

or  legs  only.  Probably,  what  are  known  as  ^^foot 
fidgets/'  which  oblige  the  sufferer  to  move  in  order  to 
get  rid  of  an  ever-recurring  sense  of  unease,  are,  too, 
of  like  parentage,  and  are  to  be  seen  in  all  degrees  of 
intensity.  I  was  lately  consulted  by  a  Western  banker, 
aged  forty  six  years,  to  appearance  well.  xS  o  organ  was 
diseased.  He  had  passed  successfully  through  a  time 
of  great  financial  trouble,  and  in  its  midst  his  wife  fell 
ill.  After  slie  recovered  he  began  to  be  a  poor  sleeper, 
and  exhibited  in  turn  a  variety  of  sleep-troubles.  He 
had  mild  forms  of  shock — i.e.,  light  and  noise.  Dis- 
use of  tobacco  aided  these  and  improved  his  sleep;  but, 
somewhat  later,  he  began  to  have  jerking  in  sleep.  An 
arm,  or  the  leg,  or  the  body  was  violently  moved,  so  as 
to  w^ake  him  up,  and  this,  he  declared,  took  place  count- 
less times  in  the  night.  Still  later  he  lay  awake  with 
uneasiness  in  the  legs.  He  moved  about  and  got  a  little 
relief.      If  he  lay  still,  he  had  to  move  again. 

These  motor  discharges  at  times  assume,  through 
their  frequency  and  severity,  sach  importance  as  to 
affect  health  by  the  destruction  of  sleep  w^iich  they 
occasion.  An  instance  is  given  in  my  book  of  a  woman 
weighing  two  hundred  pounds,  who  spent  her  nights  in 
a  series  of  motor  explosions  so  vigorous  as  at  times  to 
break  the  bed-slats.  She  has  told  me  that  she  believes 
herself  to  have  had  as  many  as  a  hundred  in  a  night  ; 
the  whole  body  moving  violently  in  sleep  with  a  jerk 
like  the  leaps  of  a  dying  fish. 

A  different  form  of  unease  is  seen  in  children  who 
nevertheless  seem  to  be  well.  Their  sleep  remains  un- 
broken, but  they  roll  over,  twist,  turn,  wriggle,  and 
continue  to  do  so  for  hours.  Possibly  they  are  dream- 
ing, but  of  this  there  is  often  no  evidence,  and  they  are 


SOME  DISORDERS  OF  SLEEP.  87 

not  affected  in  health  by  this  extraordinary  restlessness, 
which  may  remain  as  the  habit  of  a  year  or  more.  I 
have  over  and  over  watched  these  little  ones  in  a  sleep 
which  permitted  them  to  roll  over  and  bend  the  body 
and  move  the  limbs,  until  it  seemed  scarcely  possible  that 
they  could  remain  through  it  all  in  a  state  of  slumber. 
A  little  pause  might  follow  and  then  another  period  of 
nearly  constant  movement. 

In  adults  such  extremity  of  restlessness  is  very  un- 
common, and  means  more  than  in  childhood.  Of  the 
hysterical  sleepers  much  might  be  said,  but  in  them 
this  form  of  activity  during  sleep  is  seen  at  times. 

In  the  singular  ataxia  of  hysteria,  which  I  described 
a  few  years  ago,  the  early  stages  of  the  disorder  are 
apt  to  exhibit  on  waking  an  ataxic  condition,  which 
becomes  increasingly  worse,  and  at  last  continues 
through  the  waking  hours.  More  commonly  the  ataxia 
comes  on  by  degrees,  and  only  in  the  day. 

Lastly,  in  relation  to  the  motor  sphere  are  the  rare 
examples  of  chorea  seen  only  for  a  time  on  waking  from 
sleep,  of  which  elsewhere  I  find  no  mention.  As  re- 
gards this,  I  may  remark  that  some  early  ataxics  and 
some  neurasthenics  are  apt  to  be  unsure  of  their  move- 
ments for  a  little  while  after  waking. 

Case  XXIX. — A.  B.,  female,  aged  fourteen  years,  men- 
struating regularly ;  somewhat  anaemic,  but  in  other  re- 
spects healthy. 

Last  spring,  in  the  mouth  of  March,  she  Avas  attacked 
by  a  singular  form  of  chorea.  She  had  this  trouble  at  no 
time  except  in  sleep  and  on  waking  from  sleep ;  on  either 
occasion  it  occurred  in  attacks  which  did  not  last  very  long. 
Her  mother,  w^ho  frequently  watched  her  in  the  night,  said 
that  three  or  four  times  in  each  night  she  became  restless, 


88  NERVOUS  DISEASES.     ' 

kicked  off  the  covers,  and  began  to  move  her  hands,  slowly 
flexing  or  extending  them  until  at  last,  the  arms  also 
moving,  a  general  choreal  movement  ensued,  which,  at 
the  same  time,  affected  the  legs,  arms,  and  body,  but 
never  the  face.  The  attack  affected  her  almost  always 
when  she  awoke  from  slee^),  during  the  time  she  was  suf- 
fering from  this  disorder.  In  the  warm  summer  weather 
it  disappeared.  It  has  returned  again  recently.  She  has 
been  under  my  care  for  some  time,  so  that  I  have  had  an 
opportunity  of  seeing  that  she  is  a  person  in  j^erfect  health, 
with  no  organic  disease  about  her  on  which  I  can  lay  a 
finger.  The  attacks  in  the  night  are  very  rare,  but  she 
scarcely  passes  a  morning  without  waking  in  this  choreal 
condition.  The  spasm  lasts  from  a  half  to  three-quarters 
of  an  hour,  and  by  degrees  fades  away.  She  apparently 
has  no  control  over  her  movements,  and  in  this  respect 
they  differ  from  ordinary  choreas,  except  of  the  worst  kind. 

This  special  manifestation  of  chorea  must  be  ex- 
tremely rare.  In  the  experience  of  many  years  (in 
which  I  have  seen  a  multitude  of  cases)  I  recall  but 
three  or  four  of  this  character.  It  is  mostly  confined 
to  sleep  or  to  the  awakening  state,  not  apparently  ex- 
isting during  the  day.  I  have  no  hesitation,  how-ever, 
in  classing  it  as  chorea,  because  it  readily  yields  to  the 
treatment  which  is  given  to  choreal  cases,  and  because, 
in  one  instance,  it  occurred  in  a  child  who  had  had  two 
previous  attacks  of  chorea.  This  instance  is,  perhaps, 
worth  relating: 

Case  XXX. — C.  J.,  a  clever  little  boy  of  about  twelve 
years — ^not  very  strong  nor  very  active-minded  ;  never  rheu- 
matic ;  heart  normal ;  not  very  fond  of  outdoor  sports,  and 
somewhat  anaemic — was  attacked  one  spring  with  chorea, 
from  which  after  two  months  he  recovered.    The  following 


SOME  DISORDERS  OF  SLEEP.  §9 

spring  he  was  attacked  again ;  this  attack  lasted  seven 
weeks,  after  which  he  again  got  Avell.  The  next  spring  it  was 
replaced  by  the  peculiar  form  of  post-somnic  chorea  of  which 
I  have  spoken.  He  had  absolutely  no  chorea  during  the 
day.  He  usually  woke  up  about  half -past  seven  in  the 
morning  with  choreoid  movements  of  the  hands  ;  both 
sides  were  alike  affected.  They  were  not  in  character 
like  those  of  the  girl  mentioned  above,  and  were  more 
distinctly  under  control.  For  half  an  hour,  however,  he 
could  not  pick  up  anything  without  dropping  it.  What 
struck  me  with  him,  also,  was  that  the  face  was  not  con- 
cerned in  any  way,  nor  did  it  affect  either  leg.  Sensation 
did  not  appear  to  be  affected,  and  he  was  relieved  by  the 
ordinary  arsenical  treatment  and  cold  douches. 

Tonic  Spasm  is  another  rare  trouble  born  of  slum- 
ber, and  lasting  after  it.  I  quote  the  only  cases  my 
note-books  afford: 

Case  XXXI. — Mr.  J.  C,  aged  forty-five  years,  merchant, 
had  syphilis  and  distinct  secondaries  at  the  age  of  twenty- 
three  years.  Was  well  at  the  time  of  the  malady  about 
to  be  mentioned — that  is,  he  had  no  perceptible  organic 
trouble. 

About  four  years  ago  he  began  in  the  early  mornings  to 
wake  up  with  rigidity  of  the  legs.  This  was  so  extreme 
that  it  was  impossible  for  him  to  bend  the  ankles  or  knees, 
or  to  elevate  the  knees  at  all.  If  they  were  lifted  by  an- 
other with  difficulty,  they  fell  slowly  in  extension.  It  was 
truly,  therefore,  a  distinct  tonic  spasm.  If  at  that  time  he 
had  excess  or  defects  of  knee-jerk,  I  cannot  learn. 

This  state  continued  to  show  itself  for  over  two  years, 
occurring  at  intervals  ;  sometimes  taking  place  every  morn- 
ing for  a  week,  then  lapsing  for  a  month,  but  never  exist- 
ing at  other  times  than  when  he  came  out  of  sleep.  If  he 
woke  up  in  the  night,  he  occasionally  had  this  same  coudi- 

8* 


90  NER  VO  US  DISEASES. 

tion,  but  this  was  far  more  rare.  It  was  commonly  a 
mornincr  affliction,  and  lasted  for  a  few  minutes  or  at 
most  an  hour. 

After  a  certain  length  of  time  the  symptoms  disap- 
peared, but,  owing  to  a  bout  of  drinking,  they  renewed 
themselves.  Again  he  got  well,  and  a  period  of  two 
years  elapsed  without  further  trouble.  He  then  began  to 
have  vertigo,  followed  by  difficulty  in  controlling  his 
water,  and  this  was  followed  by  incoordination  and  the 
entire  range  of  ataxic  troubles  to  which  he  is  now  a 
victim. 

1  quote  another  case  as  a  still  more  remarkable 
example  of  rigidity  developed  in  sleep  and  continuing 
for  a  time  after  Avaking: 

Case  XXXII. — The  patient  was  a  man  in  good  circum- 
stances, aged  forty-five  years.  He  was  in  the  habit  occasion- 
ally of  awakening  in  the  middle  of  the  night  with  rigidity  of 
the  legs.  The  limbs  were  violently  extended,  the  feet  being 
so  completely  flexed  as  to  be  straight  with  the  line  of  the 
legs.  It  was  almost  impossible  to  lift  the  legs  without 
lifting  the  whole  trunk,  so  tightly  were  the  muscles  con- 
tracted and  so  rigid  was  the  whole  mass,  including  the 
intra-pelvic  group.  This  did  not  seem  to  be  due  to  any- 
thing in  the  way  of  specific  disease  nor  to  bad  habits. 
The  man  had  no  disease  to  which  I  could  relate  it,  except 
that  he  had  been  for  many  years  a  dweller  in  the  lower 
part  of  the  city,  and  had  had  attacks  of  ague  year  after 
year,  and  one  very  severe  attack  of  remittent  fever.  Be- 
yond this  there  was  nothing,  and  these  symptoms  had 
long  since  disappeared  ;  neither  spleen  nor  liver  was  en- 
larged, nor,  at  the  time  of  the  rigidity,  was  he  suffering 
from  any  malarial  difficulties.  The  kidneys,  heart,  and 
lungs  were  alike  sound,  and  to  tliis  day  I  remain  puzzled 
as  to  the  causation  of  this  very  peculiar  mahidy.     I  saw 


SOME  DISORDERS  OF  SLEEP.  91 

him  several  times,  because  he  used  frequently  to  ring  me 
up  in  the  night  in  order  that  I  might  witness  this  affec- 
tion, which  was  painful  from  the  intensity  of  the  contrac- 
tion of  the  muscles.  I  have  heard  him  scream  from  what 
he  described  as  "  positive  agony."  Indeed,  nothing  re- 
lieved it  except  full  hypodermatics  of  morphia,  under 
which  slowly,  within  a  couple  of  hours,  the  muscles 
would  relax,  but  always  after  an  attack  would  remain 
extremely  sore  for  days  together.  He  finally  ceased  to 
suffer. 

I  have  seen  a  disorder  of  the  same  kind^  or  some- 
thing similar,  in  hysterical  women  ;  but  even  among 
them  it  is  very  rare,  and  it  is  not  necessary  for  me  to 
go  into  details.  The  state  is  merely  an  hysterical  curi- 
osity. I  mention  it  to  complete  the  list  of  peculiar 
cases  which  I  select  from  my  note-books. 

Respiratory  Failure  in  Sleep.  I  conclude  this 
study  of  the  disorders  of  sleep  by  calling  attention 
to  one  of  very  great  interest.  I  believe  that  it  was 
first  described  by  the  late  Professor  Samuel  Jackson, 
but  I  have  been  unable  to  find  his  paper,  which  is  not 
in  the  catalogue  of  the  Army  Medical  Library.  I 
recall,  however,  hearing  him  speak  of  cases  in  his  lec- 
tures.^ 

Where,  for  some  reason,  the  respiratory  centres  are 
diseased  or  disordered,  a  man  may  possess  enough  gan- 
glionic energy  to  carry  on  breathing  well,  while  the 
waking  will  can  still  supplement  the  automatic  activity 
of  the  lower  centres.  But  in  sleep,  these  being  not 
quite  competent,  and  volition  off  guard,  there  ensues  a 
gradual  failure  of    respiration,  and  the  man  awakens 

1  Since  this  paper  was  first  published  others  Lave  called  attention  to  this 
symptom  in  sclerosis. 


92  NER  VO  US  DISEASES. 

with  a  sense  of  impending  suffocation.  This  is  not  to 
be  confounded  with  the  hysterical  sleep-symptom  of 
sense  of  suffocation,  which  is  probably  closer  to  the 
phenomenon  of  nightmare,  and  is  followed  by  or 
associated  with  fear,  and  is  soon  lost  on  awakening. 

In  the  cases  I  refer  to  the  symptom  is  sometimes  a 
signal  of  dangerous  meaning.  I  have  met  with  it  in 
extreme  neurasthenia,  but  in  worse  forms  in  locomotor 
ataxia  in  its  paralytic  stage.  I  have  never  seen  it  in 
labio-glossal  lingual  paralysis,  where  it  should  seem 
likely  to  occur.  In  ataxia  it  may  be  due  to  sudden 
incompetence  of  the  laryngeal  muscles,  Avhich  are  liable, 
late  in  ataxia,  to  become  paralyzed.  Usually,  however, 
it  appears  to  be  a  failure  of  the  chest  and  diaphragmatic 
movements. 

Case  XXXIII. — Mr,  C,  aged  fifty-six  years,  had  pos- 
terior sclerosis,  but  gave  no  evidence  iu  the  day  of  respira- 
tory incompetence,  although  he  was  distinctly  far  iu  the 
paral}i;ic  state.  When  in  deep  sleep  he  began  to  breathe 
less  and  less  deeply,  and  at  last,  for  a  few  seconds,  not  to 
breathe  at  all.  At  this  moment  he  moved,  twitched,  and 
at  last  awakened  Avith  evidences  of  commencing  apnoea 
in  the  color  of  the  lips,  tongue,  and  nails. 

When  awake  a  few  voluntary  efforts  to  respire  relieved 
him.  These  attacks  became  at  last  so  frequent  and  perilous 
that  a  nurse  sat  by  his  bed  and  awakened  him  as  soon  as 
he  began  to  breathe  less  and  less  deeply. 

As  time  went  on  the  trouble  increased,  and  whenever  he 
fell  asleep  respiration  ceased  abruptly.  He  was  finally 
worn  out  with  loss  of  slee}),  and  died  suddenly  in  one  of 
these  onsets  of  respiratory  failure.  No  post-mortem  could 
be  obtained. 

•  I  have  seen  two  other  cases,  but  none  so  remarkable 
as  that  I  have  briefly  related.     But  on  the  morning 


SOME  DISORDFAIS  OF  SLEEP.  93 

after  I  wrote  these  lines  I  saw  a  case  in  an  ataxic  not 
yet  in  the  paralytic  stage.  Just  at  the  moment  of  fall- 
ing asleep  he  feels  a  sense  of  suffocation,  fails  to  respire, 
and,  in  great  alarm,  sits  up.  These  attacks  probably 
differ  somewhat  from  those  of  sleep. 

The  type  differs  from  that  of  the  ordinary  Cheyne- 
Stokes  respiration,  being  merely  a  gradual  failure  to 
inhale — a  less  and  less  deep  inspiration,  but  no 
sequence  of  rapid  breaths  ending  in  dyspnoea. 


CHAPTER   V. 

CHOREOII)  MOVEMENTS  IX  AX  ADULT  MALE,  PROB- 
ABLY OF  HYSTERICAL  ORIGIX;  UXUSUAL  HYS- 
terical movemexts  ix  a  child;  hysterical 
:myocloxus. 

Case  XXXIY. — D.  F.,  a  white  male,  aged  thirty-seven 
years,  applied  for  treatment  December,  1894,  on  account  of 
spasmodic  to-and-fro  movements  of  the  head.  The  family 
history  is  negative,  and  the  previous  health  has  been  gen- 
erally good.  He  had  typhoid  fever  when  ten  years  old, 
and  again  Avhen  eighteen.  He  has  been  married  fourteen 
years,  and  has  had  three  children,  of  whom  one  died  of 
dysentery.  Syphilis  is  denied,  and  there  is  no  evidence  of 
it.  His  habits  were  good,  and  he  did  not  use  tobacco 
excessively. 

About  three  months  before  coming  to  the  Infirmary  he 
had  been  much  worried  about  moving  his  place  of  business 
to  some  other  part  of  the  country.  He  could  reach  no  de- 
cision, grew  nervous,  slept  little,  became  dyspeptic  and  very 
melancholy.  After  about  two  weeks  spasmodic  movements 
of  the  head  suddenly  appeared. 

Present  state.  Every  few  moments  the  head  is  forcibly 
jerked  backward  by  the  trapezii  muscles.  AVhen  lying  in 
bed  the  spasm  is  much  less  frequent.  It  is  increased  in 
frequency  during  examination,  and  for  a  time  ceases  en- 
tirely if  the  attention  be  strongly  directed  to  any  object. 
For  example,  while  looking  at  a  thermometer  bulb  the 
patient  was  quiet  for  five  minutes.  During  sleep  there  are 
no  movements  whatever.  While  in  the  hospital  he  devel- 
oped general  choreiform  movements. 


HYSTERICAL  MOVEMENTS.  95 

He  is  fairly  well  nourished.  His  expression  is  markedly 
melancholic.  Intelligence  is  good,  but  he  is  profoundly 
apathetic.  He  declares  that  he  sleeps  very  little.  His 
appetite  is  poor  and  he  suffers  much  from  gaseous  eructa- 
tions after  eating.  The  thoracic  and  abdominal  organs 
are  normal,  the  station  good,  and  the  gait  normal.  The 
urine  is  normal.  Prof,  de  Schweinitz  examined  his  eyes, 
and  reported  slight  hypermetropic  astigmatism  with  in- 
sufficiency of  the  interni. 

The  patient  was  put  at  absolute  rest  in  bed,  given  gel- 
semium,  bromide,  and  chloral,  and,  later,  hypodermatic 
injections  of  distilled  Avater.  These  had  a  very  happy 
effect  upon  his  insomnia,  and,  indeed,  caused  he  declared 
drowsiness  the  following  day.  After  about  eight  weeks' 
stay  in  the  hospital  he  was  discharged  greatly  improved, 
but  still  having  occasional  clonic  spasms  of  the  trapezii. 
There  were  no  sensory  changes.  The  man  was  emotional 
and  given  to  tears.  Soon  after  admission  he  began  to  have 
at  times,  after  exercise,  great  emotion,  or  any  excitement, 
curious  movements  of  one  limb  or  of  the  trunk.  Thus 
the  arm  would  be  extended  forcibly,  and  again  and  again 
for  a  half-hour,  or  the  leg,  or  both  legs,  with  intervals  of 
twelve  to  fourteen  seconds ;  or  the  whole  trunk,  as  he  lay, 
flopped  fish-like  until  wearied.  The  head-movements  were 
likely  to  cease  when  any  other  form  of  spasm  was  present, 
but  were,  on  the  whole,  the  most  common.  They  were 
generally  either  to-and-fro  motions  or  backward  jerks, 
seemingly  due  more  to  the  trapezii  than  to  the  other 
posterior  neck-muscles.  Over  all  of  these  movements  he 
had  temporary  volitional  control.  When  he  thus  restrained 
them  he  said  that  the  sense  of  discomfort  became  by 
degrees  really  unendurable,  and  he  had  to  ''let  go." 

Eemarks.  The  resemblance,  clinically,  to  the  cases 
of   habit-chorea  or  habit-spasm,   as    Gowers    likes  to 


96  ^^ER  VO  US  DISEASES. 

describe  the  disorder  I  first  called  attention  to  some  years 
ago,  is  very  striking.  The  lad  I  shall  show  you  to-day 
is  another  illustration  of  a  genus  of  cases  which  has 
several  related  species,  and  such  variety  as  individuality 
may  occasion.  As  in  this  case,  so  also  in  that  of  the 
boy,  hysteria  is  the  potent  agent  in  their  production. 

Case  XXXV. — B.  F.,  a  male,  aged  ten  years,  applied 
for  treatment  in  December,  1892,  complaining  of  invol- 
untary movements  of  the  head.  His  father  had  had  fits 
in  childhood,  and  one  cousin  has  had  habit-chorea.  One 
brother  died  in  convulsions  when  seven  months  old.  The 
patient  had  diphtheria  when  two  years  old,  scarlet  fever 
three  years  ago,  and  measles  last  year.  He  has  always 
been  nervous.  The  mother  states  that  he  is  the  smallest 
boy  in  his  class  and  has  always  stood  at  the  head  in  his 
studies.  She  thinks  that  overstudy  in  preparing  for  ex- 
aminations may  have  been  the  cause  of  his  illness.  The 
present  trouble  began  about  two  weeks  before  application 
for  treatment. 

There  is  constant  wagging  of  the  head  from  side  to  side, 
shrugging  of  the  shoulders,  and  winking.  The  patient  is 
a  bright,  well-made  lad,  with  excellent  muscular  develop- 
ment. The  station  is  good  with  the  eyes  closed.  The 
knee-jerks  are  capricious.  Clonus  is  absent.  The  cremas- 
teric reflex  is  present.  The  abdominal  reflexes  are  absent. 
The  elbow-jerk  is  present.  The  muscle-jerks  in  the  arms 
are  very  marked.  There  are  no  palsies.  Si:)eech  and 
sensation  are  normal.  His  physical  health  is  good,  and 
examination  reveals  no  disease  of  the  abdominal  or  tho- 
racic organs.  The  foreskin  is  very  long,  but  there  are 
no  adhesions.  There  is  no  genital  irritation  nor  any  bad 
habit. 

Prof,  de  Schweinitz  examined  his  eyes  and  reports: 
"  R.  E  ,  V.  —  15/xxx.     Round  disc,  temjioral  edges  clear ; 


HYSTERICAL  MOVEMENTS.  97 

nasal  and  upper  and  lower  margins  hidden  by  grayish  in- 
filtration ;  much  white  tissue  around  central  vessels. 
Veins  full,  arteries  normal.  L.  E.,  V.  =  15/xv  (partly). 
Similar  condition  of  disc,  but  blurring  of  disc  less  marked. 
Slight  concomitant  convergent  squint.  Eyes  Avander  in 
under  cover.  Hypermetropia  =  1.5  D.  Slight  astigma- 
tism. Diagnosis  :  hemi^neuritis  with  hypermetropic  astig- 
matism, and  slight  convergent  squint." 

The  case  was  diagnosticated  as  habit-chorea,  treatment 
given,  and  the  boy  told  to  return  in  a  week.  Two  weeks 
later  he  came  back  showing  marked  changes  in  the  symp- 
toms. Every  few  minutes  the  head  is  jerked  violently 
and  suddenly  to  the  right  or  left.  Previously  the  motions 
had  been  slow  and  gentle.  An  arm  is  very  forcibly  ex- 
tended once,  or  the  legs  are  flexed  and  extended  once. 
Similar  movements  elevate  or  depress  the  shoulders.  These 
movements  are  independent  of  each  other ;  that  is  to  say, 
at  any  given  moment  any  part  may  be  involved,  though 
oftentimes  the  legs  move  synchronously.  The  movements 
are  shock-like,  sudden,  rapid,  and  violent.  They  appear 
almost  as  if  willed.  During  sleep  they  cease  entirely. 
Emotional  excitement  increases  them  markedly.  Volun- 
tary motion  of  arm  or  leg  decreases  them  for  the  time  being 
in  the  member  used,  but  has  no  effect  upon  the  rest  of  the 
body.  While  lying  down  they  are  less  severe  than  when 
up.  There  are  no  sensory  failures.  He  was  given  Fow- 
ler's solution  in  increasing  doses  and  ordered  to  be  kept  at 
rest. 

After  a  few  days  the  movements  suddenly  ceased,  but 
were  immediately  followed  by  attacks  of  violent,  barking, 
spasmodic  cough,  so  severe  as  to  alarm  his  parents.  When 
next  seen  at  the  Infirmary  he  would  every  few  minutes 
make  a  short,  quick,  explosive,  grunting  noise.  When 
told  to  breathe  deeply  the  cough  stopped  entirely.  Atten- 
tion produced  by  having  him  fix  his  eyes  upon  a  bright 

9 


98  NER  VO  US  DISEASES, 

object  had  the  same  effect.  Slight  general  choreiform 
movements  were  also  present.  Complete  cure  followed 
his  admission  to  the  Infirmary  and  subjection  to  the  hos- 
pital discipline  in  bed  for  a  few  weeks. 

Remarks.  This  case,  as  you  see,  looks  like  wdiat 
I  venture  to  call  acute  habit-chorea.  The  same  powder 
of  control  exists  for  a  time  as  in  the  man.  The  uneasi- 
ness under  self-control  is  present.  The  abrupt  cessation 
of  other  movements  when  the  barking  or  grunting  comes 
on  is  sometimes  seen  in  habit-chorea;  but  in  that  dis- 
order there  are  usually  frequent  repetitions,  never  vio- 
lent, of  the  part  disturbed.  This  lasts  for  days  or  longer, 
and  on  ceasing  may  be  replaced  by  like  movements  else- 
where. These  children  may  or  may  not  be  hysterical, 
but  the  hysteria  of  childhood  often  fails  to  give  you  a 
complete  picture  of  that  disorder.  The  grunting  is  not 
like  the  cough  of  hysterical  ^vomen,  and  is  probably 
only  an  incidental  product  of  one  of  the  forms  of  semi- 
spasmodic  movement.  At  times  it  is  due  to  sudden 
abdominal  muscular  contractions.  Clinically  and  prac- 
tically all  this  is  interesting.  Of  this  you  may  be  sure, 
that  w^hen  adults  are  afflicted  w^ith  these  forms  of  tem- 
porarily controllable  semi-spasmodic  motions,  you  w^ill 
find  them  hard  to  get  well.  All  the  emotionalness  of 
such  temperaments  as  incline  to  motor  disorder  is  in- 
creased by  their  presence.  These  people  get  self-w^atch- 
ful,  depressed,  and  wdll-less.  Children  are  easier  to 
cure,  no  matter  how  grave  the  malady,  or  how  distinct 
the  hysteria.  Ahvays  wMth  them  developmental  change 
assists,  if  you  know  how  to  use  your  opportunities. 
Isolate  them,  if  possible.  Insist  on  mild  diet — as  of 
milk  or  vegetables,  or  these  combined.  Keep  them  at 
rest,  and  by-and-by  offer  little  bribes  to  restrain  the 


HYSTERICAL  MOVEMENTS.  99 

movements.  The  slight  cases  of  habit-spasm  may  be 
enduring,  and  the  more  severe  cases  get  well,  like  this 
good  little  fellow.  There  are  cases  which  do  not,  and 
which  develop  into  the  disastrous  states  of  mind  and 
body  I  have  delineated  in  my  Lectures  on  Nervous 
Diseases.  These  failures  are  commonly  due  to  the  folly 
of  parents.  There  is  no  worse  enemy  of  a  nervous 
child  than  a  nervous  mother.  The  peculiar  violence 
of  spontaneous  action  in  the  lad's  spasmodic  movements 
recalled  to  my  mind  a  man  who,  many  years  ago,  was 
my  patient.  He  was  subject — and  for  periods  of  a  week 
or  two — to  a  disorder  of  which,  being  a  quiet  bank-clerk, 
he  was  much  ashamed.  After  a  few  days  of  general 
uneasiness,  which  made  him  restless  and  inclined  to 
excessive  exertion,  he  began  to  have  spasmodic  actions 
— like  this  boy's — a  sense  of  profound  unease  for  a  few 
minutes,  ending  in  a  single  motion  of  abrupt  violence. 
A  leg  was  thrown  upAvard  or  back;  an  arm,  w^ith  the 
fist  clenched,  struck  out  once  with  a  look  of  purpose 
about  the  act  which  was  contradicted  by  the  fact  that 
he  had  over  and  over  hurt  his  hand  by  driving  it 
against  some  obstacle.  Once  or  twice  he  had  hurt 
others.  At  times  he  would  warn  me  or  another  of  the 
coming  risk.  No  cause  for  this  peculiar  state  was  ever 
found  ;  nor  do  I  know  what  became  of  the  man. 

Some  of  you  may  recall  the  interesting  case  seen  here 
last  year,  in  a  Hebrew  in  middle  life,  who  presented  a 
striking  illustration  of  multiple  myoclonus.  I  reported 
it  with  other  as  curious  spastic  cases  to  the  Neurolog- 
ical Association.  I  now  recall  it  to  state  that  the  man 
has  become  well  and  walks  about  like  others.  I  saw 
once,  some  years  ago,  a  similar  case,  and  it  too  was 
hysterical  and  in  a  Hebrew. 


100  NEB  VO  US  DISEASES. 

And  now  I  am  able  to  read  you  the  notes  of  a  case 
of  multiple  myoclonus,  clearly  hysterical,  a  ad  in  a  gen- 
tleman whom  I  lately  saw  in  consultation  in  a  distant 
State.  As  I  have  so  lately  discussed  the  possibility  of 
these  spasms  originating  in  the  cord,  I  shall  not  need 
to  repeat  my  remarks. 

Case  XXXVI. — C.  B.,  aged  thirty-five  years. 
Family  history.  Some  of  the  remote  ancestors  were  rather 
eccentric  or  peculiar  in  certain  directions.  His  paternal 
uncle  died,  aged  forty-five  years,  of  acute  cerebral  disease, 
said  to  have  been  encephalitis.  One  cousin,  a  son  of  this 
uncle,  has  had  incoordination  of  all  the  extremities,  cho- 
reic movements  of  the  face  accompanying  voluntary  move- 
ments only,  and  indistinctness  of  speech,  which  were  first 
noted  in  infancy,  but  were  not  thought  to  have  been  con- 
genital. 

The  mother's  labor  was  normal,  no  instruments  having 
been  used.  The  child  was  somewhat  backward  in  develoji- 
nient ;  the  anterior  fontanelle  seems  to  have  remained  open 
unusually  long.  There  were  decided  indistinctness  and 
difficulty  in  speech,  which  only  disappeared  after  some 
years.  At  school  the  boy  was  rather  slow  and  seemed 
disinclined  to  learn.  He  was  always  a  little  jDCCuliar  ;  he 
had  very  strong  opinions  on  various  subjects  which  could 
not  be  readily  influenced,  and  were  different  from  those 
natural  to  his  companions.  For  some  years  before  his 
present  attack  (six  years  ago)  he  had  been  considered 
rather  odd  by  neighbors.  When  about  seven  years  old 
he  was  thrown  out  of  a  light  wagon  and  the  wheel  passed 
over  his  head.  No  evidence  of  fracture  of  the  skull  was 
detected  and  he  seemed  well  in  a  few  days.  When  fifteen 
or  sixteen  years  old,  and  while  studying  rather  hard  at 
school,  he  began   to   have  severe  frontal,  bilateral  head- 


HYSTERICAL  MOVEMENTS.  101 

aches,  which  at  first  came  after  study  only,  but  gradually 
persisted,  although  the  study  was  given  up,  and  after  a 
time  came  in  the  mornings  without  apparent  cause,  lasting 
some  hours,  apparently  often  connected  with  the  condition 
of  the  weather,  being  Avorse  when  there  was  a  cold,  piercing, 
or  bracing  wind.  From  this  time  the  headaches  have  per- 
sisted, at  first  coming  principally  in  the  spring,  while  he 
was  free  from  them  during  the  rest  of  the  year ;  later, 
occurring  at  any  season,  and  gradually  growing  more  fre- 
quent and  more  troublesome,  so  that,  finally,  he  gave  up 
his  home  in  the  city  and  lived  entirely  in  the  country. 
Study  was  found  to  be  impossible.  Change  of  climate 
made  his  sufferings  worse.  The  patient  led  an  out-of-door 
life,  superintending  and  working  on  his  farm  until  his 
present  trouble  began.  He  was  an  unusually  large, 
strong,  and  muscularly  well-developed  man. 

The  present  trouble  began  six  years  ago,  some  time  after 
a  moral  shock  in  which  the  emotions  were  much  involved. 
He  was  attacked  with  unusually  severe  headaches,  general 
lassitude,  and  inability  to  work,  so  that  he  let  his  farm  for 
a  time  and  came  to  live  with  his  parents,  who  had  a  large 
estate  in  the  neighborhood.  While  with  them  he  was  one 
day,  when  driving,  attacked,  without  apparent  cause,  with 
a  fit  of  coughing,  which  lasted  some  minutes  and  Avas  of 
a  convulsive  character  and  so  violent  as  to  be  alarming. 
After  this  similar  attacks  of  coughing  came  on  almost 
daily,  and  seemed  to  be  aggravated  or  provoked  by 
driving.  A  few  days  later  he  began  to  have  attacks  of 
violent,  involuntary  movements  (clonic  spasms)  affecting 
the  extremities,  being  at  first  often  unilateral,  sometimes 
on  one  side  and  sometimes  on  the  other.  The  lower  ex- 
tremities were  more  affected,  on  the  whole,  than  the  upper. 
The  earlier  attacks  of  spasms  occurred  only  on  rising  in 
the  morning.  After  a  few  weeks  the  coughing-spells  were 
largely  replaced  by  hiccoughs,  and  it  was  found  that  the 

9* 


102  NER  VO  US  DISEASES. 

headaches,  the  cough,  the  hiccoughs,  and  the  motor  spasms 
were  more  or  less  interchangeable.  Since  this  time  the 
general  features  of  the  affection  have  remained  unaltered. 
The  motor  spasms  have  gradually  become  more  frequent, 
for  some  years  occurring  daily  at  stated  hours  (periodic), 
with  frequent  intervening  attacks,  and  now  several  times 
every  day.  The  motor  attacks  consist  of  very  violent,  more 
or  less  regular  movements  of  the  extremities,  especially  the 
lower,  when  violent  stamping  or  up-and-down  movements 
follow  each  other  with  great  rapidity ;  in  the  upper  ex- 
tremities there  are  regular,  coarse  movements  of  the  entire 
extremities.  These  attacks  come  on,  especially  at  the 
regular  times,  without  apparent  cause,  but  are  also  pro- 
duced at  any  time  by  a  sudden,  unexpected  touch  or  by 
any  touch  with  which  emotion  is  connected.  They  are  also 
produced  by  movement  (both  seusori-motor  and  moto-motor 
spasms). 

The  paroxysms  of  cough  disappeared  after  some  months 
to  a  considerable  extent,  w^hile  the  hiccoughs  lasted  only  a 
few  weeks,  the  place  of  both  being  apparently  taken  by  the 
larger  spasms  of  the  limbs.  During  the  last  three  years 
there  have  been  many  attacks  of  retching  and  vomiting 
(or  regurgitation),  without  nausea,  and,  for  the  last  two 
years,  attacks  of  violent  and  forcible  shouting. 

For  a  year  past  some  loss  of  strength  has  been  noticed 
and  an  increase  in  the  ease  with  which  the  spasms  are 
caused,  especially  by  walking,  so  that  they  now  largely 
preclude  any  attempt  at  exercise,  as  he  states  that  he  is 
liable  to  have  his  legs  drawn  from  under  him  violently 
and  suddenly,  so  that  he  falls  to  the  ground.  If  walking 
be  persisted  in,  in  spite  of  the  spasms,  the  headache  be- 
comes unbearable.  Of  late,  the  trunk  has  also  been  in- 
vaded by  the  spasms,  the  body  being  frequently  bent  to 
one  side,  usually  the  left ;  and  clonic  spasms  in  the  trunk- 
muscles   sometimes  last  for  hours  and  even   days  (once 


HYSTERICAL  MOVEMENTS.  103 

apparently  without  remission  for  four  clays,  but  the  patient 
was  not  seen  while  asleep),  causing  great  soreness  and  ten- 
derness in  these  muscles.  There  is  noAV  much  dizziness, 
which  began  first  six  months  ago,  and  now  causes  an 
additional  difiiculty  in  walking. 

He  has  taken  food  irregularly  for  years  ;  of  late,  not  more 
than  one  meal  of  solids  a  day,  and  that  usually  at  11  p.m., 
and  the  rest  of  the  time  weak  coffee  or  milk  when  wished 
for.  The  bowels  are  regular;  the  urine  negative.  The 
face  is  now  usually  pale,  but  becomes  turgid  and  congested 
during  attacks,  partly  from  the  violence  of  the  motion. 
The  intellect  is  unimpaired  (broadly  speaking).  Sleep  has 
been  good. 

Remarks.  This  gentleman,  unlike  our  former  case, 
is  in  easy  circumstances.  It  were  better  he  Avere  not, 
as  he  is  able  to  control  his  own  surroundings  and  to 
isolate  himself  as  he  pleases.  The  limitations  to  which 
the  position,  age,  and  circumstances  of  the  case  subject 
our  therapeutics  must  be  clear  to  you.  When  I  first 
examined  this  most  expressively  hysterical  case  I  found 
my  patient  up,  and  after  a  partial  examination,  with 
increasing  signs  of  fear  and  nervousness,  he  went  to 
bed.  There  I  completed  a  long,  but,  of  necessity,  im- 
perfect study.  He  was  a  rather  well-built,  well-colored 
man,  with  no  organic  troubles.  As  I  went  on  to  make 
the  ordinary  search  as  to  sensation,  reflexes,  etc.,  all 
being  normal,  he  became  all  the  time  more  and  more 
convulsed.  If  I  touched  a  leg,  it  passed  at  once  into 
violent  convulsion,  and  this  at  times  involved  all  four 
limbs,  and  was  so  terrible  that  I  thought  the  bed  would 
be  broken.  When  he  tried  to  walk,  and  always  then 
if  emotionally  disturbed,  he  ^vould  begin  to  stamp  in  a 
strange  way  and  with  swiftly  increasing  force,  and  this 


104  NEB  VO  US  DISEASES. 

spastic  state,  reaching  the  trunk,  seemed  then  to  draw 
him  down,  so  that  he  fell  or  contrived  to  get  back  to 
the  bed.  I  was  obliged  at  last  to  cut  short  my  exam- 
ination, but  not  before,  with  the  aid  of  his  physician, 
I  was  able  to  reach  very  distinct  conclusions. 

Cases  of  violent  hysteria  in  the  male  are  not  common, 
at  least  in  America.  Only  once  in  my  life  have  I 
seen  a  male  exhibit  all  the  acts  in  the  long  drama  of 
hysteria  precisely  as  we  so  often  see  them  in  the  female. 
I  now  add  the  opinion  given  in  the  case  of  Mr.  C.  B. 
A  careful  consideration  of  the  symptoms  brings  me  to 
three  conclusions: 

1.  That  the  form  of  the  convulsive  attacks  brings 
this  disorder  closer  to  the  clinical  delineations  of  myo- 
clonus than  to  those  of  any  other  group  of  symptoms. 
He  is  liable  to  have  violent  stamping,  or  worse,  from 
standing — i.  e. ,  sole-pressure  causes  it.  Also,  when  cog- 
nizant of  it,  a  mere  touch  anywhere  brings  on  clonic 
spasms  of  the  legs,  or  of  the  arms  under  like  circum- 
stances. Voluntary  motion  may,  as  in  other  cases, 
give  rise  to  like  spasms — I.  e,  the  spasms  as  to  cause 
may  be  sensori-motor  or  moto-motor. 

2.  Evidently  attention  increases  the  severity  of  sen- 
sori-motor manifestations. 

3.  For  various  reasons,  this  myoclonus  seems  to  me 
hysterical.  The  transfers,  the  interchangeableness  of 
spasms,  headache,  regurgitation,  hiccough,  and  vocal 
symptoms,  all  point  this  way.  So  do  the  type  of  lar- 
yngeal phenomena  and  the  characteristic  regurgitation 
without  nausea;  and  that  the  first  spasms  followed  a 
grave  emotional  disturbance  assists  us  to  a  like  conclu- 
sion.    The  original  injury  may  have  been  coutributive, 


HYSTERICAL  MOVEMENTS.  105 

but  there  is  not  in  the  skull  any  distinct  local  evidence 
of  organic  lesion. 

If  it  all  be  at  last  hysteria,  or  due  to  the  injury  but 
in  its  outcome  hysteric,  one  might  look  to  find  sensory 
changes;  bnt  close  examination  of  the  skin  is  impossi- 
ble, and  without  ether  I  could  not  see  the  eye-grounds 
as  I  wished  to  do.  It  would  be  worth  while  once  to 
do  this  under  ether.  Probably  the  spasms  have  their 
birth  in  the  cord.  They  seem  to  me  in  quality  and 
history  functional,  and  I  ought  to  add  that,  when  off 
guard — a  rare  thing — the  touch  of  my  hand  does  not 
occasion  spasm,  nor  does  his  own  touch  of  himself, 
unless,  having  been  asked  if  it  be  so  capable,  he  with 
pre-attention  touches  himself. 

Probably  he  is  incurable,  but  this  does  not  imply  the 
certainty  of  his  not  losing  the  spasm.  If  he  were  a  lad, 
I  should  take  him  away,  and  with  isolation,  massage, 
and  electricity  treat  him,  and  have  hope.  Now,  I  do 
not  advise  it.  I  should  like  to  see  hypnotism  used.  I 
would  assuredly  use  arsenic  for  a  year.  I  would  not 
let  him  live  wholly  alone  or  unvisited  by  friends,  as  he 
now  wishes. 

Hypodermatic  use  of  arsenic  is  to  be  considered. 

I  have  little  doubt  that  the  injury  may  have  been  the 
ultimate  cause  of  headache,  and  that  he  has  had  more 
or  less  of  chronic  meningitis.  If  he  could  have  a  good 
study  of  the  eyes  by  an  expert,  I  should  feel  better 
satisfied,  as  the  eyes  may,  with  slight  ocular  defects,  be 
competent  to  trouble  a  defective  brain.  Also,  the  color- 
fields  might  prove  very  interesting. 

I  gather  enough  in  various  ways  to  make  me  think 
that  Mr.  C.  B.  was  never  a  perfectly  normal  person  in 
earlier  youth.      When,  to  a  person  of   such  neurotic 


106  NER  VO  US  DISEASES. 

type,  come  accident,  emotions,  etc. ,  then  the  worst  and 
the  more  unusual  results  are  to  be  apprehended. 

Yet  a  word  before  I  close  the  lesson  of  the  day.  I 
have  used  the  label  hysteria  again  and  again.  It  is, 
and  as  yet  mast  be,  a  word  of  somewhat  loose  employ- 
ment. I  am  not  sure  that  it  is  just  to  apply  it  here, 
because  with  spastic  or  other  symptoms  the  patient  is 
merely  emotional;  but  certainly  we,  by  common  con- 
sent, do  this,  especially  in  the  unusual  forms  of  spasm 
and  in  cases  in  which  clearly  emotion  was  the  parent 
of  spasms.  When  we  have  areas  of  anaesthesia  we  use 
the  term  in  question  with  lessened  doubt.  If,  too,  we 
find  these,  and  Avith  them  optical  anaesthesia  for  colors 
or  especially  reversals  of  the  color-fields,  our  doubts  are 
further  lessened.  But,  after  all,  it  is  the  grouped  condi- 
tions which  fully  justify  such  clinical  labels.  Dr,  J. 
K.  Mitchell  and  Prof,  de  Schweinitz  have  shown  how 
much  our  American  experience  as  to  the  eye-symptoms 
of  hysteria  may  vary  from  that  of  the  French  observers. 


CHAPTER   VI. 


I  DESIRE  to  draw  attention  to  a  single  symptom  which 
has  not,  hitherto,  received  sufficient  notice;  it  is  not  of 
extreme  rarity. 

The  cases  I  sliall  report  are  characterized  by  the 
facts  that  the  patient  complains  of  local  or  general  cold- 
ness, and  that,  as  a  rule,  the  parts  involved  have  no 
abnormal  temperature,  or  have  one  the  reverse  of  that 
complained  of.  No  doubt  there  are  in  medical  litera- 
ture many  such  records,  but  they  must  be  buried  in 
cases  which,  being  reported  under  other  titles,  are  diffi- 
cult to  find.  In  the  catalogue  of  the  Army  Medical 
Library  there  is  no  heading  which  covers  this  symptom. 
The  meagre  material  which  I  possess  could,  with  time, 
have  been  made  larger,  as  I  find  that  almost  every  phy- 
sician has  met  with  cases  of  the  kind  I  am  about  to 
recount.  I  liave  enougli,  however,  to  enable  me  to  make 
a  rough  division  of  my  cases  into  at  least  three  classes: 

Class  I.  has  a  central  cause,  and  must  be  of  great 
rarity. 

Class  II.  is  frequently  due  to  neuritis,  and  is  not  very 
uncommon.  It  contains  cases  which  lack  the  remain- 
ing qualities  of  neuritis,  and  may  or  may  not  be  due  to 
local  inflammatory  nerve-states. 

Class  III.  is  inexplicable  or  hysterical,  and  the  phe- 
nomena are  commonly  unilateral,  as  in  the  first  class. 

1  Transactions  of  the  Association  of  American  Physicians  and  Pathologists, 
1895. 


108  NEB  VO  US  DISEASES. 

As  these  cases  have  not  occurred  to  me  in  such  com- 
petent numbers  as  to  enable  me  to  generalize  largely,  I 
shall  relate  them  with  what  comment  each  suggests. 

Class  I.  In  this  class  I  have  but  a  single  case,  but 
it  is  so  remarkable  that  I  am  glad  to  present  it  for  con- 
sideration. 

Case  XXXVII. — Sir  P.  Broke  was  seriously  wounded 
in  the  head  in  the  fight  between  the  "  Chesapeake"  and 
the  "Shannon,"  in  1813.  He  received  a  severe  sabre- 
wound  on  the  head  while  boarding  the  "  Chesapeake." 
Of  the  later  consequences  of  this  Avound  I  find  no  very 
distinct  account  in  the  loosely  Avritten  and  tedious  biog- 
raphy of  the  patient. 

*  On  August  8,  1820,  Sir  P.  Broke  had  a  fall  from  his 
horse,  which  he  described  as  follows : 

"  I  was  stunned  by  the  fall,  but  it  was  only  for  a 
moment,  for  I  was  certainly  dragged  only  a  few  yards  ; 
and  I  chiefly  remember,  as  my  first  perception  after  the 
fall,  that  I  was  lying  on  my  back  and  looking  upAvard  at 
my  foot  in  the  stirrup.  I  certainly  got  up  unconscious  of 
injury  and  walked  about  a  quarter  of  a  mile  to  my 
mother's  house,  whence  I  had  just  departed.  I  remember 
nothing  of  this  walk,  and  my  recollection  recommences 
with  my  sitting  down  quietly  in  the  room  and  telling  her 
I  had  had  a  fall.  I  began  in  a  few  minutes  to  have  some 
sense  of  stupor,  as  from  a  blow  on  my  head,  and,  having 
gone  upstairs  to  wash  the  dirt  off  my  head,  I  then  dis- 
covered that  my  head  was  scratched  in  several  places  and 
bleeding.  The  stupor  became  more  oppressive,  and  I  sent 
for  a  surgeon,  who  bled  me  in  the  left  arm,  taking  away 
ten  or  twelve  ounces  of  blood.  This  might  be  about  an 
hour  and  a  half  after  the  accident.  The  stupor  increased 
considerably ;  I  was  persuaded  to  go  upstairs  again  and 
go  to  bed.  This  I  clearly  remember,  and  that  while  pull- 
ing my  clothes  off  a  violent  retching  and  vomiting  came 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     109 

on,  and  then  my  memory  again  failed  me  for  several  hours  ; 
but  on  the  following  morning  I  was  perfectly  clear  again 
and  had  some  good  sleep.  I  felt  the  usual  soreness  in  the 
head  from  such  contusions,  but  had  no  hurt  in  any  part 
of  the  body  nor  any  uneasiness  in  my  stomach,  and  my 
appetite  was  unimpaired.  I  felt  weak,  but  unconscious  of 
any  material  injury  beyond  the  bruises  I  had  received. 

"The  usual  treatment  in  such  cases  was  resorted  to  to 
prevent  inflammation,  and  successfully,  though  my  bodily 
powers  were  thereby,  of  course,  considerably  weakened. 
The  first  symptoms  that  I  remember  of  any  affection  of  the 
nerves  were  my  perceiving,  in  the  afternoon  of  the  day  fol- 
lowing the  accident,  a  sense  of  extreme  cold  in  my  leg 
and  foot  and  left  hand,  so  that  I  could  not  sleep  in  com- 
fort without  a  worsted  glove  and  worsted  stocking ;  and  in 
the  course  of  the  next  day  I  discovered  that  the  whole  of 
the  left  side  was  strangely  affected,  the  sense  of  cold  ap- 
pearing to  lie  internally  upon  the  coating  of  the  bones  of 
the  arm,  thigh,  and  leg ;  and  that,  though  the  flesh  exter- 
nally was  warm  to  the  touch  and  generally  in  a  state  of 
perspiration,  and  though  the  skin  appeared  perfectly  fresh 
and  smooth,  without  any  sign  of  withering  or  contraction, 
yet  that  skin  over  the  whole  left  side  of  my  person  was 
affected  with  a  singular  numbness  to  the  touch. 

"After  a  time  it  became  necessary  to  consult  Sir  Astley 
Cooper,  who  wrote  to  Dr.  Lynn  in  the  following  language  : 

"  '  I  have  heard  from  Sir  P.  Broke  a  minute  detail  of 
his  feelings  and  an  accurate  history  of  his  case.  The  situa- 
tion appears  to  be  as  follows :  On  the  left  side  of  the  head 
the  sabre-cut  has  depressed  the  bone  and  compressed  the 
brain  ;  and  as  the  edges  of  the  fracture,  which  are  displaced, 
have  long  since  united  to  the  skull,  all  expectation  of  any 
change  in  that  part  must  be  abandoned,  and  the  diminished 
nervous  energy  of  the  right  side,  consequent  upon  this  in- 
jury, will  continue  without  variation. 

10 


110  NEE  VO  US  DISEASES. 

"  'Not  so  in  the  right  side.  There  the  mischief  has 
been  an  extravasation  of  blood  upon  the  brain  or  its  mem- 
branes, and  from  decussation  of  nerves  from  the  brain  to 
the  body  the  left  side  is  suffering  from  diminished  tempera- 
ture or  power  of  resisting  its  changes,  and  from  altered 
sensations.  The  heart  is  subject  to  occasional  alteration  in 
its  functions  from  diminished  nervous  excitability,  and 
hence  the  pain  felt  in  its  region  and  the  sense  of  strangu- 
lation under  which  Sir  P.  Broke  occasionally  labors.  The 
stomach  is  also  occasionally  suffering  from  its  sympathy 
w^ith  the  brain,  and  hence  those  attacks  which  drinking 
warm  water  alleviates.  Congestion  in  the  brain  from 
changes  in  position  and  from  over-exertion  of  mind  tends 
to  a  sudden  increase  of  all  the  symptoms  ;  but  this  is  tem- 
porary only.  The  probability  is  that  the  blood  will  gradu- 
ally absorb  if  Sir  Philip's  general  health  be  supported  and 
he  avoids  too  much  mental  excitement  and  he  preserves 
his  body  from  humid  circulation.'  " 

Nothing  is  said  further  either  by  Sir  A.  Cooper  or  the 
biographer  of  Sir  Philip  in  regard  to  the  very  interesting 
symptoms  described  ;  but  in  Guthrie's  Military  Surgery, 
where  first  I  lit  on  the  case,  that  author  thus  describes  it : 

"Admiral  Sir  P.  Broke  received  a  cut  with  a  sword 
on  boarding  the  *  Chesapeake,'  on  the  left  side  of  the 
back  of  the  head,  which  went  through  his  skull,  render- 
ing the  brain  visible ;  the  wound  healed  in  six  months. 
After  temporary  paralysis  of  the  right  side  he  recovered, 
with  a  loss  of  power  and  a  disordered  sensation  in  the  sec- 
ond, third,  and  little  fingers  of  the  right  hand,  aggravated 
by  cold  weather  and  by  mental  anxiety. 

"  Seven  years  afterward  he  fell  from  his  horse  and  suf- 
fered from  concussion  of  the  brain,  which  added  to  his 
former  sensations  by  rendering  the  left  half  of  his  whole 
person  incapable  of  resisting  cold  or  of  evolving  heat.  In 
a  still  atmosphere  abroad,  at  68°  F.,  he  said,  '  the  left  side 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     H] 

requires  four  coatings  of  stout  flannel,  which  are  augmented 
as  the  thermometer  descends  every  two  degrees  and  a  half, 
to  prevent  a  painful  sense  of  cold  ;  so  that  when  it  stands 
at  freezing-point  the  quantity  of  clothing  of  the  affected 
side  becomes  extremely  burdensome.  When  exposed  to  a 
breeze,  or  in  moving  against  the  air,  one  or  even  two  oil- 
skin coverings  are  necessary,  in  addition,  to  prevent  a  sen- 
sation of  j)iercing  cold  driving  through  the  whole  frame.' 
Moderate  horse  exercise  and  generous  diet  improved  the 
general  health  ;  the  warm  bath  caused  a  distressing  effect ; 
the  shower-bath,  cold  or  tepid,  increased  the  paralytic  affec- 
tion. Frictions  with  remedies  of  all  kinds  increased  it 
also,  and  so  did  sponging  with  vinegar  and  water,  as  well 
as  any  violent,  stimulating,  quick  excitement  or  earnest 
attention  to  any  particular  subject.  The  Admiral  died 
unrelieved,  twenty-six  years  after  the  receipt  of  the  injury, 
of  disease  of  the  bladder." 

Owing  to  the  rather  vague  statements  of  the  surgeons 
and  the  biographer,  we  can  only  infer  that  iho;  fall  may 
have  given  rise  to  a  rupture  of  a  vessel,  supra-  or  sub- 
meningeal  hemorrhage,  slight  motor  loss,  and  irritative 
disturbance  of  sensory  regions,  causing  numbness  of  the 
opposite  side  and  false  sense  of  cold. 

Occasionally,  in  hemiplegia,  coldness  is  a  symptom 
mentioned  by  the  patient,  but  not  much  complained  of.  I 
recall  no  case  like  this  one,  but  I  have  distinct  remem- 
brances of  at  least  two  instances  of  probable  clots  involv- 
ing the  internal  capsule  and  optic  thalamus,  causing  lack 
of  muscular  sense  and  numbness  on  the  left  side.  In 
both  unilateral  sense  of  cold  was  felt,  although  there 
was  no  fall  of  temperature.  In  one  of  them  the  anaes- 
thesia w^as  notable,  so  that  pin-pricks  were  not  felt  and 
did  not  bleed.     Both  were  adult  males. 

In  cases  of  hemiplegia  it  is  desirable  to  know  not 


112  NER  VO  US  DISEASES. 

only  the  actual  temperatures  of  the  two  sides,  but  also 
how  w^ell  cold  and  heat  are  distinguished  on  both  sides: 
and,  lastly,  if  there  be  abnormal  subjective  sensation 
of  either  cold  or  heat  on  the  palsied  side;  and,  too,  the 
date  of  this  symptom  relatively  to  the  attack — because, 
clearly  enough,  even  in  a  cerebral  paralysis,  the  later 
comino;  on  of  false  feelings  of  cold  or  heat  in  the  ex- 
tremities  may  be  due  to  peripheral  neuritis. 

Class  II.  Local  sensations  of  cold  loithout  lowered 
local  temperatures. 

The  three  cases  which  follow  are  none  of  them  as  full 
as  is  now  desirable,  because  the  notes  were  made  as 
mere  memoranda  for  use  in  the  conduct  of  the  cases, 
and  before  I  began  to  feel  a  larger  interest  in  the  symp- 
tom. All  three  were  affected  in  the  lower  half  of  the 
body — two  of  them  especially  in  the  buttock,  which 
is  a  not  rare  seat  of  the  symptom  in  question. 

Case  XXXVIII.  (Case  281  in  Xote-book.)  Local  sen- 
sation of  cold  in  the  buttocks. — J.  P.,  single  ;  aged  fifty-three 
years  ;  Connecticut.  The  patient  was  a  man  of  fortune, 
and  had  gone  through  a  variety  of  excesses,  chiefly  sexual. 
He  had  had  gonorrhoea,  but  never  syphiHs.  There  had 
been  attacks  of  pain  in  the  legs,  arms,  and  back,  and  these 
had  been  in  a  measure  relieved  by  various  means  before 
he  came  under  my  care.  He  also  had  a  variety  of  vague 
gastric  symptoms,  which  grew  out  of  the  hypochondriacal 
state.  He  had  had  tingling  of  both  legs  and  feet,  some 
loss  of  power  in  the  right  arm,  tenderness  upon  pressure 
along  many  nerve-tracks,  and  a  difiiculty  of  using  his  brain 
for  prolonged  mental  exertion,  which  I  believe  to  have 
been  of  small  moment. 

The  one  symptom  on  account  of  which  I  have  mentioned 
this  case  was  the  constant  complaint  of  coldness. 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     II3 

When  seen  by  me  he  was  ruddy,  in  good  flesh,  and  had 
no  organic  disease  of  any  of  the  viscera. 

The  nerve-tracks  above  the  waist  were  not  sensitive,  and 
he  had  long  been  free  from  neuritic  symptoms  of  the  arms. 
The  two  sciatic  nerves  were  slightly  tender  from  the  exit- 
points  to  the  knee.  The  electrical  tests  gave  normal  re- 
sults. The  statioD-sway  was  antero-dextral,  and  good ;  knee- 
jerk,  right  seven  inches,  left  one  inch,  but  sensory  reinforce- 
ments added  to  the  knee-jerk  three  inches  or  more  right  and 
left.  Motor  reinforcements  added  about  two  inches  right 
and  left.  Superficial  reflexes  were  normal.  Sexual  power 
somewhat  lessened.  Excessive  exercise  increased  the  ten- 
derness and  also  exaggerated  the  sense  of  coldness.  This 
symptom  began  to  be  felt  before  he  complained  of  distinct 
pain  in  any  region,  and  his  aches  w^ere  so  much  better  that 
it  was  merely  the  coldness  w^hich  brought  him  to  me.  This 
was  positive  and  most  distressing.  It  affected  both  but- 
tocks and  the  upper  half  of  the  back  of  both  thighs,  and 
was  as  intense  as  if  he  were  seated  on  ice.  Occasionally 
the  calves  suffered. 

I  saw  him  but  once,  and  I  do  not  know  how  the  case 
resulted.  The  parts  complained  of  were  warm  to  the  touch, 
but  I  took  no  note  of  the  actual  local  temperatures. 

Case  XXXIX.  (Case  840  in  Xote-book.)  Subjective  sen- 
sation of  cold  ill  buttocks  with  actual  elevation  of  temperature. 
— J.  P.  C. ,  coal  dealer ;  aged  fifty-two  years.  No  syphilis 
or  gonorrhoea  ;  much  on  his  feet ;  uses  neither  tobacco  nor 
alcohol.  Married,  has  tAvo  children.  Family  healthy  and 
long-lived.  The  patient  lives  in  a  somewhat  malarious 
portion  of  New  Jersey,  but  has  not,  himself,  been  subjected 
to  positive  ague. 

About  eighteen  months  ago,  having  been  more  than 
usually  afoot  and  somewhat  worried  by  business  annoy- 
ances, he  began  to  have  a  painful  sensation  of  cold  in 
the  left  gluteal  region,  and  down  the  back  of  the  thigh 

10* 


1 1 4  NEB  VO  US  DISEA  SES. 

nearly  to  the  knee.     There  was  nothing  of  the  kind  in  the 
other  leg.     This  trouble  increased  gradually  until  it  be- 
came so  positive  that  he  was  in  constant  discomfort.     It 
has  varied  very  little  up  to  the  present  time,  and,  although 
better  in  summer,  is  yet  distinctly  felt  through  the  warmest 
weather.     Heat  at  all  times  makes  him  feel  comfortable, 
and  the  greatest  amount  of  relief  is  obtained  by  standing 
with  his  back  to  a  hot  fire.     As  soon  as  he  leaves  the  fire, 
however,  the  sensation  of  cold  returns  with  all  its  vigor, 
and,  in  fact,  rarely  leaves  him.     There  is  no  perceptible 
pain  in  the  parts  affected.     His  station  is  good  ;  his  knee- 
jerk  is  normal,  three  and  one-half  inches,  and  capable  of 
ready  reinforcement,  both  sensory  and  motor.     The  ankle- 
jerk  is  present  and  reinforcible  ;  there  is  no  clonus.    Super- 
ficial reflexes  exist  in  integrity.     Electrical  reaction  of  the 
limbs  normal ;  water  and  bowel  mechanism  perfect ;  but  he 
thinks  that  since  this  trouble  began  his  sexual  power  has 
lessened.     Digestion  is  good,  appetite  fair.    All  secretions 
normal.    His  eyes  are  exceptionally  good,  since  he  is  not 
yet  obliged    to  wear  glasses.     An  actual  examination  of 
the  temperature  shows  the  left  buttock   to    be  distinctly 
warmer  than  the  right ;  it  was   found  to  be  J°  to  ^°  F. 
higher  than  on  the  right  side.     The  exit-point  of  the  left 
sciatic  was  at  times  tender.     He  declares  himself  to  be  not 
as  strong  as  he  was.     He  is  somewhat  paler,  and  has  lost 
from  four  to  five  pounds  of  flesh.    Always  in  the  morning, 
on  rising,  he  is  nervous — as  he  says,  a  "  little  trembly." 
There  seemed  to  be  no  indications,  except  to  look  after  the 
manifest  failure  of  his  general  health.    Quinine  and  arsenic 
had  already  failed,  and  long  hohdays  in  the   mountains 
proved  valueless.     Iron  was  given  in  moderate  doses,  as 
well  as  strychnine  and  cod-liver  oil.     Within  a  week  or 
two  he  began  to  gain  in  health.    His  weight  improved,  but 
there  w^as  no  relief  from  the  sensation  of  cold.     Accord- 
ingly, I  advised  local  miussage ;  l)ut  after  its  use  the  parts 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     115 

seemed  colder  than  ever — that  is  to  say,  when  the  actual 
temperature  of  the  parts  went  up  ^°  to  1°  F.  under  mas- 
sage the  sensation  to  the  patient  was  as  if  the  part  had 
become  colder.  He  was  under  the  impression  that  gal- 
vanic electricity  locally  was  of  service,  but  exercise  did 
not  improve  his  condition.  After  many  months'  treatment, 
during  which  I  saw  him  occasionally,  he  had  gained  largely 
in  general  health  and  freedom  from  nervousness,  and  in 
capacity  to  do  his  work  with  his  usual  energy ;  yet,  not- 
withstanding, there  was  the  same  constant  sensation  of 
local  cold. 

I  think  malaria  may  be  ruled  out  as  a  cause  of  his 
trouble.  The  most  careful  study  showed  uo  local  ten- 
derness, except  as  stated.  There  was  at  times,  after  long 
exertion,  slight  tingling  of  the  left  foot. 

This  case  was  one  of  real  suffering;  the  ache  of  the 
cold  was  intense  and  disqualifying.  In  the  light  of 
other  cases  I  suspect  this  to  have  been  a  neuritic  con- 
dition. The  increase  of  warmth  from  massage  was  felt 
as  cold,  and  this  is  interesting,  since  he  had  a  quite 
normal  appreciation  of  applied  cold  and  heat. 

Case  XL.  (Case  821  in  Note-book.)  Subjective  sen- 
sation of  cold. — Mr.  C.  S.,  aged  sixty-three  years  ;  glass 
manufacturer.  Patient  has  no  bad  habits ;  has  never 
had  syphilis.  He  has  been  for  many  years  an  extremely 
active  business  man,  weighted  with  many  responsibilities 
and  constantly  afoot.  There  are  no  head-symptoms.  He 
sleeps  well,  has  a  good  appetite,  and  there  are  no  gastro- 
intestinal troubles. 

Five  years  ago  he  had  some  difficulty  in  passing  water, 
and,  later  on,  a  return  of  the  same  trouble,  which  appeared 
on  examination  to  be  due  to  an  enlargement  of  the  pros- 
tatic gland.  Within  a  few  months  he  found  that  exercise 
tired  him,  especially  mounting  stairs.      There  is  now  no 


116  NEB  VO  US  DISEASES. 

cardiac  lesion  to  account  for  the  difficulty,  and  the  arteries 
are  in  unusually  good  order.  There  is  a  distinct  lack  of 
power  in  both  legs,  and,  in  walking,  he  does  not  use  the  left 
foot  as  well  as  he  should.  His  station  is  good  ;  his  sway, 
standing  with  his  eyes  shut,  is  antero-dextral,  not  exceed- 
ing an  inch  in  either  direction.  The  knee-jerk  is  normal, 
three  and  one-half  inches ;  reinforcements  are  normal. 
There  is  no  clonus,  and  no  perceptible  loss  of  sensation  in 
the  legs  and  arms,  either  as  to  touch,  pain,  or  temperature. 
There  is  no  tingling  or  numbness.  The  mixed  urine  of 
the  night  and  morning  contains  two  grains  of  sugar  to  the 
ounce,  but  no  albumin  or  casts.  None  of  these  symptoms 
were  such  as  to  alarm  him  or  cause  him  to  consult  me. 
He  attributed  them  all  to  overwork  and  to  being  too  much 
afoot. 

That  which  drove  him  to  seek  my  advice  was  a  slowly 
increasing  and  very  positive  sensation  of  cold,  from  the 
Avaist  down  to  the  calves  of  the  legs,  and  limited  to  the 
posterior  half  of  the  body.  It  was  usually  most  severe  on 
the  right  side,  but  varies  a  great  deal,  sometimes  being  felt 
more  on  the  left.  The  sensation  is  described  as  being 
equivalent  to  that  which  would  be  experienced  by  sitting 
long  on  ice.  It  caused  him  to  desire  to  cover  the  parts 
concerned  with  an  excessive  amount  of  clothing.  As  the 
cold  was  apparently  lessened  by  motion,  he  kept  afoot, 
when  evidently  his  general  condition  demanded  that  he 
should  not.  He  tells  me  that  at  times,  after  active  mo- 
tion, he  has  some  sense  of  numbness  down  the  back  of  the 
right  leg  in  the  region  affected  with  the  false  sense  of  cold. 
I  could  find  no  notable  difference  between  the  temperature 
of  the  two  sides  of  the  body  in  the  regions  Avhere  he  suf- 
fered, but,  as  both  had  more  or  less  of  the  same  trouble,  it 
was  natural  that  the  temperature  should  not  differ  greatly. 
Normal  surface-temperatures  are  apt  to  vary  in  different 
individuals,  and  to  a  far  greater  extent  than  interior  tem- 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     117 

peratures.  There  is  no  standard  so  exact  as  to  enable  per- 
sons to  compare  with  it  surface-temperature  of  a  case  like 
this  ;  undoubtedly,  however,  the  temperature  was  not  below 
normal.  The  masseur  who  rubbed  him  insisted  that  at 
times  the  buttocks  were  warmer  than  they  usually  are. 

My  patient  improved  rapidly  under  tonic  treatment 
and  proper  diet — in  fact,  the  sugar  disappeared  entirely — 
and  he  regained  full  health  after  a  few  months  of  care. 
The  unpleasant  sensation  of  cold  was  the  last  symptom  to 
leave  him.  It  is  as  well  to  say,  in  conclusion,  that  my 
patient  was  not  a  nervous  man,  nor  was  he  hypochondri- 
acal. He  was  rather  disposed  to  underrate  than  to  over- 
rate his  symptoms.  The  complaint  he  made  of  the  sense 
of  cold  was  most  positive  ;  at  times  the  sensation  was  so 
distinct  that  he  could  hardly  keep  himself  from  believing 
that  some  cold  application  was  being  applied  to  the  parts 
in  question. 

In  this  case  there  was  do  sensitiveness  of  the  lower 
nerveSj  but  a  sharp  blow  on  the  sacrum  with  a  rubber 
hammer  was  felt  in  a  dull,  deep  pain,  somewhat  lasting, 
and  it  seems  possible  that  in  this,  as  in  the  other  cases 
of  buttock-cold,  there  may  be  obscure  commencements 
of  neuritic  trouble  in  the  cauda  equina.  The  sensation 
of  coldness  of  the  buttocks  is  not  excessively  rare.  I 
have  seen  it  from  time  to  time,  and  now  that  my  atten- 
tion has  been  directed  to  a  possible  cause,  I  shall,  per- 
haps, be  better  able  in  future  to  relate  the  symptom  to 
its  probable  parentage  neuritis. 

Case  XLI.  (Case  935  in  Private  Note-book.)  Subjective 
sensation  of  cold  in  the  right  foot,  ivith  actual  increase  of 
temperature  in  the  parts. — J.  C,  male,  aged  fifty-two  years, 
a  native  of  Pennsylvania,  by  occupation  a  clerk.  Has 
had  perfect  health.  Never  had  syphilis.  Stands  on  his 
feet  at  work  for  seven  hours  a  day.     Is  married  ;  has  six 


118  NERVOUS  DISEASES. 

children,  all  well.  He  lives  in  a  coimtiy  which  is  not 
malarious,  a  mouutainous  region  1000  feet  above  the 
sea. 

About  five  years  ago  Mr.  C.  found  that  his  right  foot 
became  painfully  cold  after  standing  for  a  length  of  time. 
Even  when  in  a  warm  room  he  was  inclined  to  dress  that  leg 
warmly — often  wore  two  pairs  of  socks  and  an  "arctic" 
rubber  shoe,  heavily  lined.  At  this  early  period  he  found 
that  the  parts  affected  were  not  cold  to  the  touch,  and 
were  apt  to  be  more  flushed  than  the  other  foot. 

As  the  summer  progressed  (and  this  has  been  the  case 
nearly  every  summer  since)  the  foot  became  better.  At 
times  all  that  summer  it  was  tender,  and  Avas  eased  by  his 
sitting  doAvn.  In  the  winter  which  followed  the  impres- 
sion that  the  foot  was  cold  was  often  so  intense  that  he 
would  go  from  his  work  and  remove  the  covering  from 
the  limb  and  ask  some  one  to  examine  the  foot  to  see  if 
it  were  not  frozen.  The  observer  called  upon  was  apt  to 
say  that  it  felt  warm  to  the  touch.  His  general  health 
remained  good.  He  was  able  to  do  his  work,  and  lived  a 
tranquil  life  until  a  few  weeks  ago,  when  symptoms  occurred 
which  caused  him  to  consult  me. 

I  found  him  a  man  of  fairly  robust  appearance,  of  good 
color,  with  no  history  of  specific  or  malarial  poison.  His 
heart  and  kidneys  were  healthy,  and  there  were  no  pecu- 
liarities which  I  need  mention  except  those  concerned  with 
the  foot.  About  six  weeks  before  he  came  to  me — that  is 
to  say,  the  end  of  January,  1887 — the  foot  became  more 
and  more  troublesome,  and  he  began  to  have  also  a  ting- 
ling sensation  on  the  right  side  of  the  head  in  the  scalp, 
and  also  in  the  hand  on  the  same  side.  These  symptoms 
came  on  suddenly  one  day,  Avhen  he  was  rising  in  the 
morning.  They  have  now  passed  away.  The  other  head- 
symptom  of  which  he  complains  (and  which  he  insists  he 
did  not  have  before  the  symptoms   just  mentioned)  is  a 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     II9 

sensation  of  roaring  in  the  head,  accompanied  with  a  throb- 
bing in  the  vertex.  The  dynamometer  showed  good  results 
for  both  hands.  His  foot  and  its  conditions  are  what  give 
him  most  trouble,  and  it  is  for  these  that  he  consults  me. 

Of  the  present  state  of  his  symptoms  he  gives  me  the 
following  account :  He  is  better  in  summer  than  in  winter, 
although  at  all  seasons  the  foot  becomes  distressingly  cold 
when  he  has  been  standing  on  it  for  more  than  half  an 
hour.  To  sit  eases  it  somewhat ;  to  put  it  u^  on  a  chair 
eases  it  more  ;  lying  in  bed  for  some  time  gives  him  the 
greatest  relief,  as  when  he  wakes  in  the  morning  the  foot 
seems  to  be  warm.  An  upright  position  has  an  immediate 
effect.  He  says,  when  that  position  is  assumed,  the  hg 
seems  to  become  cold  to  the  knee.  There  is  absolutely  no 
difference  in  the  appearance  of  the  two  limbs,  whether  he  is 
standing  or  is  lying  down.  The  knee-jerk  on  both  sides  is 
equal  and  normal,  the  other  reflexes  good,  as  w^ell  as  the 
electric  reactions.  The  sensory  appreciations  of  all  kinds 
are  natural.  Both  feet  are  flatter  than  they  should  be,  but 
I  could  find  no  trace  of  tenderness  in  either.  The  tem- 
perature of  the  right  foot  was  1°  F.  higher  than  that  of  the 
left  foot.  On  one  occasion  Seguin's  surface-thermometer 
(arbitrary)  marked  6°  difference  of  the  right  as  above  the 
left;  and  these  peculiarities  of  temperature  were  the  same 
when  the  left  foot  was  placed  in  the  same  physical  condi- 
tions as  the  right.  The  sciatic  nerves  behind  the  knee  were 
quite  tender.  I  did  not  study  the  temperature-sense,  as  it 
was  long  ago,  and  I  was  not  awake  to  the  value  of  this  as 
a  symptom.     Treatment  proved  of  little  value. 

This  case  was,  probably,  also  a  neuritic  affection.  In 
some  ways  it  resembles  the  remarkable  cases  which 
I  described  as  erythromelalgia.  In  them,  however, 
there  v/ere  pronounced  vaso-motor  disturbances,  with 
excessive  pain.     Of  late  it  has  been  pointed  out  that  in 


1 20  ^ER  VO  US  DISEASES. 

some  cases  of  positive  neuritis  the  capacity  to  be  aware 
of  degrees  of  cold  applied  to  the  skin  is  present,  while 
the  like  power  to  distinguish  heat  is  lost.^  This  symp- 
tom existed  in  none  of  my  cases ;  but  I  may  not  have 
too  carefully  looked  for  it.  I  have  observed  it  in  hys- 
teria and  seen  the  reverse  condition,  and  also  that  heat 
could  cause  pain  when  the  needle  did  not.  But  this 
part  of  symptomatology  needs  careful  re-examination. 
Meanwhile  I  may  conclude  that  a  sense  of  intense  local 
coldness  should  cause  us  to  suspect  neuritis  as  a  cause. 
I  had  last  winter  a  sad  case  of  general  neuritis  in  a 
Avoman.  Exercise  increased  it  enormously,  and  when 
it  became  Avorse  in  any  part  there  was  iu  that  nerve- 
territory  a  painful  sense  of  cold,  with  very  often  rise  of 
temperature  and  local  enlargement  of  the  veins,  but  no 
notable  incapacity  to  discriminate  temperatures. 

I  may  add,  as  regards  all  these  cases,  that  mere  vasal 
states  do  not  suffice  to  explain  the  false  sense  of  intense 
local  coldness.  If  they  be  of  local  peripheral  origin, 
we  must  assume  that  the  nerves  are  then  constantly  in 
a  physical  state  such  as  is  present  when  true  cold  is 
applied. 

The  condition  of  false  sense  of  heat  is  to  be  met  with, 
as  is  well  known.  For  myself,  I  have  never  yet  felt 
sure  that  there  are  distinct  nerves  for  perceiving  heat 
or  cold.  Another  theory  is  possible,  as  I  have  else- 
where stated  in  regard  to  pain  and  touch. 

My  next  case  of  intensified  capacity  to  feel  cold  stands 
alone,  but  I  am  sure  it  will  not  do  so  very  long.  I  owe 
it  to  the  kindness  of  Dr.  Kinnicutt.  Exactly  the  re- 
verse state  is  to  be  seen  most  often  in  the  insane,  but  I 

1  George  W.  Jacoby  :  Journal  of  Mental  and  Nervous  Disease,  June,  1889. 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     121 

reserve  the  cases  of  false  sense  of  heat,  local  or  general, 
for  another  paper.     They  offer  greater  difficnlties. 

Case  XLII. — L.  P.,  Kansas,  aged  fifty-seven  years, 
lawyer.  When  a  youth,  aged  seventeen,  the  patient  suf- 
fered from  a  renal  complication  during  an  attack  of 
scarlet  fever.  Albumin  has  been  found  almost  constantly 
in  his  urine  from  that  date,  and  casts  very  frequently.  He 
has,  nevertheless,  enjoyed  good  health,  and  although  his 
urine  still  contains  albumin,  and  hyaline  and  granular  casts 
are  occasionally  found,  he  is  in  excellent  condition,  and 
performs  all  his  varied  legal  duties  easily.  On  careful  ex- 
amination there  are  no  signs  of  cardiac  or  vascular  changes. 
The  heart  is  not  hypertrophied.  There  is  no  marked  arte- 
rial tension  and  no  appreciable  change  in  the  vessel-walls. 

For  the  past  six  or  seven  years  he  has  been  greatly  an- 
noyed by  subjective  sensations  of  cold.  These  sensations 
are  general,  but  are  particularly  marked  along  the  inner 
aspect  of  the  upper  arm  ;  they  are  greatly  increased  by 
mental  application.  To  relieve  these  sensations  he  wears 
at  present  three  suits  of  the  heaviest  woollen  undercloth- 
ing, three  pairs  of  the  heaviest  woollen  socks,  felt  boots 
made  expressly  for  him  of  the  heaviest  material,  over  his 
ordinary  boots  or  shoes,  and  a  flannel  bandage  around  the 
abdomen.  At  night  he  wears  two  of  the  above  suits,  a 
flannel  chest-protector,  and  the  Avoollen  socks.  He  sleeps 
under  five  double  blankets,  on  a  feather  mattress  with  a 
hair  one  underneath.  Moreover,  he  is  obliged  to  keep  the 
night-temperature  of  his  room  at  80°,  and  after  an  un- 
usually hard  day  at  court  at  90°  or  95°. 

The  only  change  of  underclothing  that  he  makes  in 
summer  is  the  doing  away  wdth  one  of  the  three  suits. 
The  sensations  of  cold  are  positively  painful.  I  have 
made  inquiry  as  to  the  truth  of  his  statements  concern- 
ing the  amount  of  clothing  worn,  and  they  are  borne  out 
by  my  examinations.     The  surface- temperature  is  normal, 

11 


1 22  NER  VO  US  DISEASES. 

even  when  he  complains  most  bitterly  of  his  symptoms. 
He  has  a  highly  sensitive  and  nervons  organization,  with 
an  active  mind.  He  is  well-balanced,  cheerful,  and  philo- 
sophical about  his  sufferings.  He  walks  from  five  to  six 
miles  daily  without  fatigue — on  the  contrary,  with  benefit. 
He  is  absolutely  free  from  the  ordinary  symptoms  of  hys- 
teria, and  has  no  pain  and  no  tenderness  along  the  nerve- 
tracts. 

This  case  is  calculated  to  make  us  reflect  upon  the 
ordinary  standards  of  heat  and  cold.  They  vary  with 
individuals,  with  social  classes,  and  with  periods  of  life, 
as  the  aged  Avell  know.  The  present  case  is  that  of 
a  man  abnormally  susceptible  to  cold.  Explanation 
I  have  none  to  offer.  It  is  interesting  to  be  assured 
that  a  man  may  have  tube-casts  in  his  urine  for  forty 
years  and  yet  preserve  a  standard  of  general  health 
and  activity. 

Class  III.  Finally,  I  give  a  case  of  false  sense  of 
cold  in  an  hysterical  woman.  Such  cases  must  be  rare. 
The  reversed  state  I  have  also  seen  in  the  hysterical 
more  than  once. 

Case  XLIII.  (Case  409  in  Private  Xote-book.)— Miss 
B.,  aged  thirty-three  years,  Pennsylvania.  The  patient  in 
this  case  was  a  young  woman  in  easy  circumstances,  for 
many  years  a  victim  to  hysterical  conditions,  first  acute  and 
afterward  chronic.  To  describe  her  case  would  be  to 
describe  almost  every  form  which  hysteria  assumes. 

At  seventeen  she  began  to  be  irregular  as  to  her  men- 
strual periods,  and  at  last  passed  into  a  condition  of  hys- 
terical stupor,  then  into  catalepsy,  and  later  had  for  several 
weeks  onsets  of  hystero-epilepsy.  At  last,  coming  out  of 
this  condition,  she  suffered  for  a  long  while  from  attacks 
of  rigidity,  the  left  leg  finally  remaining  at  an  angle  to 
the  trunk  and  knee.     Next,  several  months  passed  away, 


SUBJECTIVE  FALSE  SENSATIONS  OF  COLD.     123 

during  which  she  continued  subject  to  slight  hysterical 
attacks,  and  then  by  degrees  improved  so  as  to  be  fairly 
well.  She  was  an  emotional  and  very  intelligent  woman, 
fond  of  reading  and  devoted  to  music.  She  exercised  but 
little,  however,  and  was,  when  I  first  saw  her,  again  drift- 
ing into  a  life  of  invalidism. 

About  two  months  before  she  came  to  me  she  passed  over 
one  menstrual  time,  and  during  the  month  which  followed 
began  to  have  a  sense  of  cold  on  the  left  side  of  the  body. 
This  condition  arose  quite  gradually,  and  became  at  last 
so  violent  as  to  compel  her  to  wear,  on  that  side,  two  or 
three  times  the  amount  of  clothing  required  on  the  other. 
This  excessive  increase  of  clothing  made  her  so  ridiculously 
one-sided  that  she  was  ashamed  to  be  seen  in  public.  She 
continued  to  dress  in  this  peculiar  fashion,  rarely  leaving 
the  house,  and  presented  an  appearance  more  easily  imag- 
ined than  described. 

I  first  saw  her  early  in  February,  1883.  She  was  then 
a  woman  of  fair  general  appearance,  Avith  nothing  notably 
wrong  in  any  organ,  and  with  all  the  secretions  in  good 
order.  She  had  had  no  hysterical  attack  for  several  months. 
Menstruation  was  natural,  almost  without  pain  at  her  last 
period.  iVt  this  time,  however,  she  complained  of  a  diffi- 
culty in  swallowing  and  of  a  sensation  as  of  a  band  around 
her  throat.  The  whole  left  side  of  the  body  was  still  sub- 
ject to  the  sensation  of  cold  to  which  I  have  alluded,  and 
which  affected  also  the  same  side  of  the  face,  head,  and 
neck.  There  was  no  loss  of  sensation  to  the  touch  on  this 
side — in  fact,  there  were  hyperiesthetic  spaces,  one  below 
the  left  breast  and  one  below  the  floating  ribs  on  the  left. 
This  region  of  tenderness  continued  to  the  middle  line  and 
down  to  the  pubes.  The  special  senses  were  normal,  and 
there  Avas  no  change  in  the  color-fields. 

In  the  discussion  which  followed  Dr.  James  J.  Put- 
nam said:    ^^  In  chronic  spinal  disease  and  in  chronic 


124  ^'EB  VO  US  DISEASES. 

neuritis  I  have  seen  the  coldness  to  which  Dr.  Mitchell 
refers.  This  was  quite  marked  in  one  case  which  I  shall 
report  in  my  paper.  This  patient  suffers  from  sensory 
neuritis  which  may  possibly  be  due  to  lead.  The  sensa- 
tion of  cold  is  present  to  an  extreme  degree.  In  regard 
to  the  sensation  of  cold  in  persons  not  presenting  signs  of 
anaemic  neuritis,  I  am  not  familiar  with  anything  like 
what  has  been  reported,  though  I  have  seen  cases  in 
which  there  w^ere  sensations  of  excessive  heat,  without 
organic  disease.' ' 

Dr.  C.  K.  Mills  said:  ''  I  think  that  the  sensation  of 
cold  is  a  very  important  symptom  of  neuritis.  I  have 
seen  it  in  one  case  of  acute  neuritis  of  the  ulnar  nerve 
followed  by  paralysis  of  the  muscles  of  the  hand. 
During  the  hottest  summer  weather  the  patient  had  to 
wear  a  great  deal  of  extra  wrapping  on  the  arm.  Often 
a  sensation  of  extreme  heat  follows  injury  of  the  ner- 
vous system,  either  peripheral  or  central.  I  recollect 
that  after  the  attempted  assassination  of  Garfield  the 
description  that  he  is  said  to  have  given  of  the  feelings 
in  his  feet  was  that  of  extreme  burning.  I  remember 
having  expressed  at  that  time  the  idea  that  the  spinal 
cord  was  involved.'^ 


CHAPTER  VII. 


RETAINED    MUSCLE-EEFLEXES;     PERNICIOUS    ANAE- 
MIA, WITH    LOCOMOTOR   ATAXIA   AND    HYSTERIA. 

This  child,  whose  parents  kindly  permit  me  to  shoAV 
him  to  you,  has  a  form  of  malady  which  I  saw  for  the 
first  time  when  I  saw  him  last  week.  Here  is  a  fine 
little  man,  well  developed,  exceedingly  strong,  and  as 
intelligent  as  most  children  at  his  age.  He  is  quite 
unable  to  stand  alone.  Even  to  sit  alone  seems  diffi- 
cult. No  one  will  fail  to  note  that  he  is  ataxic  from 
head  to  feet.  The  following  notes  of  his  condition  at 
the  present  time  are  compiled  from  the  examination 
record  made  by  Dr.  John  K.  INIitchell,  and  the  very 
clearly  written  statement  of  the  father: 

Case  XLIV. — P.  Q.,  male,  three  years  and  five  months 
of  age. 

Family  history.  The  child's  grandfather  was  addicted  to 
alcohol.  The  parents  are  second  cousins,  and  much  alike 
in  disposition  and  general  characteristics.  There  is  also 
some  tuberculous  history  in  the  ancestry. 

The  child  was  born  normally  at  term.  No  instruments 
were  used.  The  only  thing  attracting  attention  at  the 
time  of  birth  was  "something  unusual"  about  the  Httle 
one's  ankles.  The  physician  said  it  was  "all  right,"  and 
the  babe  seemed  otherwise  healthy  ;  the  child  cried,  kicked, 
nursed  from  the  breast,  etc.  Owing  to  mammary  abscesses 
the  mother  nursed  the  infant  no  more  than  four  weeks 

11* 


126  NERVOUS  DISEASES. 

After  that  the  chikl  lived  on  uon-sterilized  cows'  milk,  and 
later  on  "malted  milk"  and  other  artificial  foods  until 
eight  months  of  age,  and  with  sustained  good  health. 

At  that  time,  however  (eight  months  of  age),  the  child 
was  taken  on  a  railroad  journey.  It  is  supposed  that  "  sour 
milk  "  was  the  cause  of  a  severe  attack  of  diarrhoea,  which 
resulted,  a  few  days  later,  in  what  the  physician  writes  was 
"spurious  hydrocephalus;  the  temperature  103.5°  F." 
The  chikl  threw  its  hands  about,  especially  toward  the 
head,  and  moaned  a  great  deal.  It  had  also  "intolerance 
of  light "  at  this  time. 

The  physician  gave  a  cool  bath  and  a  dose  of  brandy. 
By  the  next  day  the  patient  is  said  to  have  recovered  from 
the  serious  symptoms,  including  the  diarrhoea. 

After  this  attack  of  bowel-trouble  digestion  seemed  as 
well  i^erformed  as  usual.  Two  months  later  (/.  e.,  at  ten 
mouths  of  age)  it  Avas  specially  noticed  that  the  child  could 
not  sit  erect.  Nothing  had  seemed  abnormal  until  now 
other  than  undue  lassitude.  On  examination.  Dr.  J.  S. 
Hackney  found  that ' '  there  was  an  antero-posterior  curva- 
ture of  the  spine,"  the  most  prominent  point  being  about 
the  mid-dorsal  region. 

Accordingly  a  plaster  jacket  was  applied.  This  was 
cut  and  removed  as  often  as  necessary.  There  seemed  to 
be  some  relief  from  this  for  the  now  evidently  weak  back. 
The  jacket  was  worn  for  six  weeks. 

The  little  patient  has  kept  up  a  general  good  tone  since 
then,  the  back  seeming  to  have  become  straight  and  quite 
strong  again ;  nor  has  he  had  any  bowel-complaint  since 
that  in  his  first  summer. 

The  present  condition  seems  to  date  from  thirteen  months 
of  age,  when  the  child  began  to  have  an  oscillatory  move- 
ment of  the  left  eye  and  later  of  the  right  eye.  This  nys- 
tagmus was  always  the  more  noticeable  in  the  left  eye. 
At  this  time,  too,  his  health  was  good.     He  seemed  some- 


MOTOR  ATAXIA.  127 

what  nervous,  but  did  not  have  any  convulsive  movements, 
and  never  has  had  any  such  tendency. 

At  fourteen  months  of  age  he  had  an  attack  of  bronchitis. 
In  the  second  week  of  this  illness  symptoms  of  what  was 
said  to  have  been  tuberculous  meningitis  made  their  appear- 
ance. Both  bronchial  and  meningeal  symptoms,  however, 
disappeared  during  the  third  week.  Since  then  and  until 
now  the  child  has  enjoyed  very  good  health,  excepting  for 
extreme  nervousness  during  the  illness  stated.  He  now 
became  easily  startled  and  scared.  This  timidity  has  be- 
come more  apparent  as  he  grows  older.  He  is  at  present 
unusually  sensitive.  His  father  says  the  mental  faculties 
are  normal  or  even  precocious. 

The  child  did  not  move  about  if  placed  on  the  floor  until 
two  years  old.  It  has  only  been  since  January,  1894  (three 
years  and  two  mouths  old),  that  he  has  begun  to  pull  him- 
self up  to  a  standing  position  with  his  arms  and  the  aid  of 
a  chair,  bed,  etc.  Now,  when  up,  he  can  walk  along  the 
side  of  the  bed  or  balusters,  holding  firmly  for  support. 
This  ability  has  been  acquired  only  within  the  past  few 
months.  Even  when  thus  holding  himself  upon  his  feet  he 
seems  in  fear  of  falling. 

The  patient  has  been  extremely  constipated  until  about 
a  year  ago.  Since  then  the  bowels  have  been  reasonably 
regular.  This  change  has  probably  been  brought  about  by 
the  greater  physical  exertion  of  attempted  movement. 

The  child  is  rather  pale ;  the  muscles  are  fair  in  size, 
but  very  flabby.  The  head  is  large,  but  symmetrical.  The 
chest  is  large — indeed  unusually  full  for  a  child.  He  does 
not  crawl,  but  he  can  shuffle  about,  seated ;  he  can  walk 
about  when  supported,  but  with  a  marked  ataxic  gait  and 
with  feebleness.  He  jerks  the  legs  forward  in  the  effort 
at  locomotion.  The  erectores  spinas  are  weak.  The  ab- 
dominal muscles  and  thigh  muscles  do  not  hold  the  body 
steadily  upright  on  the  legs.     He  leans  too  far  forward  or 


128  ^EE  VO  US  DISEASES. 

back.  The  tendency  is  more  backward,  however,  when  he 
is  thus  supported.     He  cannot  feed  himself. 

Incoordination  is  marked  in  the  hands,  but  there  is  no 
tremor.  He  uses  the  left  hand  better  than  the  right,  and 
possibly  the  left  leg  a  little  better  than  the  right  one. 

Nervous  system.  Sensation  is  perfect  everywhere.  Knee- 
jerks  and  elbow-jerks  are  normal  and  no  ankle-clonus  exists. 
Muscle-jerks  of  the  arms  and  legs  give  normal  response  on 
stimulation  with  the  percussion-hammer.  Electrical  ex- 
amination shows  no  alteration  to  faradism  or  galvanism. 
The  child  seems  intelligent  and  alert,  though  timid  and 
nervous.  No  signs  of  pain  were  elicited  at  any  time  dur- 
ing the  examinations.  He  talks  fairly,  drawls  his  words 
somewhat,  but  speaks  freely.  The  mouth  and  teeth  are 
normal.  There  is  no  preputial  adhesion,  no  incontinence 
of  urine,  and  this  excretion  is  normal. 

Eyes  (examined  by  Dr.  A.  G.  Thomson).  The  ' '  puj^ils 
react  normally  to  light  and  accommodation.  There  is  no 
choked  disc.  The  nystagmus  of  both  eyes  and  the  con- 
vergent squint  of  the  left  eye  are,  therefore,  not  due  to 
any  refractive  error,"  but  are  incoordinate  movements, 
such  as  are  seen  in  other  parts  of  the  body. 

All  other  functions  and  organs  are  normal. 

It  seems  reasonably  clear  that  the  cause  of  tliis  inter- 
esting malady  was  not  prenatal.  The  child  remained 
well  until  he  had  the  too  common  experience  of  summer 
diarrhoea,  follow^ed,  as  we  see  so  often,  by  brief  brain- 
symptoms.  What  happened  then  is  not  now^  clearly 
known.  He  is  said  to  have  had  "  spurious  hydroceph- 
alus/' and  was,  according  to  the  note,  very  ill.  At  or 
after  this  time  he  could  not  sit  up  as  he  had  been  able 
to  do.  At  the  thirteenth  month  nystagmus  began,  or 
was  first  seen.  Then  followed  a  bronchitis  and  brain- 
symptoms  described  as  ''  tuberculous  meningitis,"  and 


MOTOR  ATAXIA.  129 

from  this  too  he  got  well,  but  was  seen  to  be  more  and 
more  awkward  as  he  grew  older. 

I  confess  to  some  puzzle  in  this  case.  There  are  no 
eye-ground  signs.  There  is  no  wasting.  There  is  no 
palsy  of  any  nerve.  There  is  unusual  power  from 
crown  to  sole;  there  is  no  sensory  loss,  and  yet  he  can- 
not stand  at  all  without  some  stay.  Aided  by  a  finger 
he  can  walk,  throwing  his  feet  out,  and  ^^  clumping" 
precisely  like  a  true  spinal  ataxic.  But  no  such  case 
in  an  adult  had  ever  such  a  degree  of  disorder  without 
disturbed  feeling,  or  pain,  or  anaesthesia,  or  girdle-pain, 
or  pu2)illary  signs.  Here  are  none  of  these.  Also, 
the  ataxia  is  in  all  the  limbs,  but  is  worse  in  the  legs. 
In  the  arms  and  legs,  to  my  surprise,  I  found  normal 
tendon-jerks,  so  called,  and  also  normal  reinforcements 
of  these  muscle-reflexes.  There  is  nothing  spastic  in 
these.  Sometimes  they  are  excessive,  probably  from 
reinforcement  due  to  emotion.  There  is  no  clonus  ;  but 
this  is  rare  in  the  child  under  any  conditions.  If  this 
were  spinal  ataxia,  with  added  lateral  sclerosis,  we 
should  have  spastic  reflex  signals  and  the  usual  feeble- 
ness apt  to  be  seen  in  that  disorder;  also  the  high  ataxic 
movement  of  the  feet  seen  in  our  case  would  be  want- 
ing. 

Tabes  of  all  kinds  is,  as  a  rule,  progressive.  The 
lad  before  you  continuously  improves  in  the  use  of  his 
limbs.  This  is,  therefore,  neither  tabes  nor  spastic 
ataxia,  nor  is  it  the  picture  of  hereditary  ataxia;  neither 
has  he  pain-crises  nor  trophic  changes,  so  that  probably 
the  posterior  nerve-roots  and  the  gray  spinal  centres  are 
to  be  excluded  from  a  share  in  this  disorder. 

It  vseems  to  me  possible  that  the  double  brain-diseases 
he  is  said  to  have  had,  and  which  left  his  power  of 


1 30  NER  VO  US  DISEA  SES. 

mind  and  of  mnscle  nnimpaired,  may  have  fallen  on 
the  cerebellum  and  left  it  permanently  injured  in  one 
of  its  functions.  As  against  this  is  the  lad's  gain  in 
steadiness;  but  even  with  most  of  the  cerebellum  gone 
birds  have  after  a  year  been  able  to  fly.  The  mechan- 
isms of  replacement  of  function  are  not  as  yet  clear  to 
us,  although  we  are  often  called  on  to  recognize  their 
value. 

It  is  possible  that  the  cerebellum  may  have  suffered 
over  a  large  area  of  the  surface,  and  that  this  damage 
may  have  been  in  part  repaired,  and  a  share  of  the 
functional  activities  safe-guarded  and  replaced  by  the 
other  mechanisms  which  contribute  to  the  integrity  of 
equilibration. 

I  cannot  say,  however,  that  I  am,  even  now,  entirely 
sure  as  to  a  cerebellar  lesion  being  the  true  cause  of  the 
ataxic  state  seen  in  this  child;  but  it  cannot  be  spinal 
unless  the  ataxia  of  childhood  should  prove  to  be  a  very 
different  condition  from  that  of  the  adult — an  ataxia 
without  sensory,  ocular,  or  reflex  symptoms.  If  we 
had  any  evidence  of  tumor  of  the  cerebellum,  we  should 
be  aided  in  our  diagnosis.  In  it  there  may  be  preser- 
vation of  the  knee-jerk,  but  we  have  here  no  sign  of 
tumor. 

I  confess,  as  I  study  this  case,  to  increasing  difficulty 
of  decision;  as  one  looks  at  it,  the  case  is  to  the  eye  a 
typical  spinal  ataxia ;  examined  more  nearly,  much  is 
lacking  to  make  the  perfect  picture  of  that  disorder  or 
disease.  But  almost  as  much  is  also  wanting  to  assure 
us  of  a  cerebellar  origin;  and  one  should  remember,  I 
repeat,  that  we  have  hardly  any  studies  of  spinal  ataxia 
in  childhood.     I  reported  one  years  ago,  which  came  out 


MOTOR  ATAXIA.  131 

of  Pott's  disease,  at  the  age  of  five,  and  was  seen  by 
me  in  a  woman  of  forty.  It  had  progressed  in  leaps, 
with  long  periods  of  pathological  inactivity. 

When  so  thoughtful  a  man  as  Gowers  admits  that  the 
grouped  symptoms  seen  in  locomotor  ataxia  may  be  due 
to  disease  either  of  the  cord  or  of  the  peripheral  nerves, 
one  sees  the  tano^le  into  which  we  have  gotten  our 
knowledge  of  the  mechanism  of  harmonious  muscle- 
action,  and  its  offspring,  equilibration. 

As  there  may  be  much  loss  of  motor  power,  much 
impairment  of  motor  centres  aud  nerves,  without  cor- 
responding loss  of  muscle-harmonies,  we  must,  I  think, 
still  look  to  disease  of  the  nerves  of  muscular  sensation, 
their  spinal  tracts,  and  their  cerebellar  connection,  for 
the  varied  seats  of  the  incoordination  of  complex  muscle- 
acts. 

It  is  conceded  that  integrity  of  the  knee-jerk,  or  any 
tendon-jerk  from  a  blow  on  the  tendon,  implies  Avhole- 
ness  of  the  neural  arc  of  conduction  and  response  from 
the  centres  concerned.  When  there  is  distinct,  typical 
ataxia  without  spastic  states,  and  with  normal  preser- 
vation of  knee-jerk  and  ankle-jerk,  it  seems  reasonable 
to  conclude  that  the  cause  of  this  ataxia  must  lie  above 
the  region  concerned  in  the  muscle-muscle-reactions. ^ 
The  law  which  applies  to  knee-jerks  and  all  tendon- 
jerks  explains  in  part  the  direct  muscle- jerk  from  a  blow. 
For  here,  as  Morris  Lewis  and  I  have  shown,  this  re- 
sponse is  due  to  two  contributions,  one  the  intrinsic 
muscular  irritability,  and  one  the  addition  from  the 
cord.  The  former  continues  after  nerve-section;  the 
latter  is  lost,  but  its  loss  is  only  to  be  proved  by  the  fact 

1  Contra-distinguished  from  skin-muscle-reflexes. 


1 32  NER  VO  US  DISEASES. 

that  you  can  then  no  longer  reinforce  the  direct  muscle- 
jerk  by  remote  voluntary  motion. 

Such  is  the  case  late  in  posterior  sclerosis.  A  blow 
on  the  muscle  causes  a  jerk,  but  reinforcement  is  no 
longer  possible.  The  response  from  tendon-jerk  is 
ouly  a  finer,  a  more  delicate,  expression,  and  a  larger 
one,  of  the  same  phenomenon.  In  this  boy  neither 
muscle-jerk  nor  tendon-jerk  is  gone,  nor  yet  their  rein- 
forcement. 

The  facts  as  to  all  this  matter  of  sensory  motor  as 
well  as  motor  reinforcement  in  its  varied  forms,  discov- 
ered by  Lewis  and  myself,  remain  as  yet  almost  un- 
noticed in  the  text-books,  and  nnnsed  by  clinical  in- 
quirers. 

As  regards  this  boy  I  conclude,  then,  that  the  cause 
of  his  remarkable  ataxic  state  must  lie  above  the  seat  of 
response  to  the  tendon-jerks,  and  does  not  interfere  with 
the  track  of  reinforcement,  which  is  easily  obtainable. 

I  must  leave  this  case  and  its  consideration  without 
further  words.  I  do  not  fully  understand  it,  and  the 
frank  statement  that  I  do  not  may  have  for  you  some 
moral  value.  Under  training,  with  constant  little 
bribes  to  do  this  or  that  until  he  succeeds,  the  lad  is 
steadily  improving,  and  has  continued  so  to  do  up  to  the 
later  date  of  July,  1896.  Even  ordinary  ataxics  may 
improve  by  industrious  efforts  made  with  closed  eyes, 
and  this  child  has  in  his  favor  a  normal  mind  and 
entirely  wholesome  nutrition. 

An  equally  interesting  case  for  study  is  a  woman 
now  in  McCormick  ward.  Dr.  Walker  will  read  the 
notes,  which  owe  much  of  their  interest  to  Dr.  Musser, 
in  whose  charge  she  has  been  at  the  Presbyterian  Hos- 
pital; and  to  Dr.  Pearce,  who  is  responsible  for  the 


MOTOR  ATAXIA.  133 

blood-counts  made  for  Dr.  John  K.  Mitchell's  pa2:>er  on 
the  influence  of  massage  on  the  blood-count. 

I  shall  presently  show  you  the  case.  It  is  another 
illustration  of  clinical  difficulty  in  decision.  Here 
again  we  have  an  example  of  ataxia,  typical  and  also 
extreme,  with,  save  for  one  notable  exception,  perfect 
knee-jerks  and  elbow-jerks  and  entire  muscle-jerks  from 
a  blow,  and  all  reinf orcible : 

Case  XLV. — E.  I.,  female,  single,  aged  fifty  years,  was 
admitted  to  the  Infirmary  for  Nervous  Diseases,  in  my 
service,  March  2,  1894.  She  is  intelligent,  and  gives  the 
following  history  as  to  her  illness,  amplified  by  the  obser- 
vations at  the  Presbyterian  Hospital  and  by  our  later 
notes : 

Family  history.  The  woman  is  of  a  long-lived  ancestry. 
Her  father  and  mother  are  living  and  well  at  eighty-two 
and  seventy-five  years  respectively.  Three  sisters  are  all 
healthy.  Two  brothers  have  died  of  scarlet  fever  and  dys- 
entery, and  one  sister  in  infancy.  There  are  no  neuroses 
or  psychoses  among  her  relatives,  and  the  patient  herself 
had  an  uneventful  childhood  as  regards  maladies,  passing 
through  mild  forms  of  the  usual  diseases  of  youth. 

In  1887  she  suffered  from  the  ordinary  symptoms  of 
nervous  exhaustion,  had  anorexia,  and  felt  tired  most  of 
the  day.  These  symptoms  ran  the  course  of  many  of  such 
cases  when  ill  cared  for.  After  an  attack  of  influenza, 
in  1889,  she  was  almost  bedridden  for  a  year  from  what 
she  says  was  "  weakness  "  only. 

She  was  about  again  for  several   months,  able  to  walk 

with   a  cane,  but   could  not   bear   much   exertion.     She 

was  especially  weak  in  the   spine  and  had   considerable 

pain  across  the  lumbar  region.     The  patient  also  states 

that  at  this  time  she  always  had  better  use  of  the  right 

fo6t  than  of  the  left — the  latter  was  heavy  and  seemed  to 

''drag"  in  walking. 

12 


134  NER  VO  US  DISEASES. 

She  coutiuued  iu  this  way  with  but  little  change  in  the 
foregoing  meagre  symptomatology  until  July,  1890,  when 
she  went  to  the  Cooper  Hospital,  Camden,  remaining  there 
three  months,  with  little  or  no  improvement ;  thence  she 
was  taken  to  the  Presbyterian  Hosj^ital,  Philadelphia, 
where  she  stayed  in  the  wards  one  year.  There  she  was 
in  a  highly  neurotic  condition,  and  had  hysterical  outbursts 
of  crying  and  laughing.  The  sequelae  of  these  climaxes 
(which  occurred,  as  a  rule,  near  the  menstrual  epochs)  were 
states  of  lethargy  and  again  of  fear,  in  which  temporary 
hysterical  delusions  became  prominent.  The  sick  women 
about  her  were  often  much  frightened  by  her  pecuhar, 
wandering  talk.  In  a  few  days  she  was  apt  to  regain 
partial  control,  and  would  censure  herself  for  acting  so 
foolishly — of  which,  however,  she  had  only  vague  remem- 
brances. At  this  time,  too,  she  seemed  able  to  walk  only 
with  the  assistance  of  a  nurse,  and  but  for  short  distances. 
Her  upper  extremities  also  were  weak,  and  she  was  clumsy. 
It  was,  therefore,  with  difficulty  that  she  fed  or  assisted  in 
dressing  herself.  Under  rest  and  tonics  there  was  improve- 
ment of  the  general  health,  and  on  leaving  the  hospital  she 
was  able  to  walk  a  short  distance  with  the  aid  of  a  cane. 
She  was  then  at  home  from  March  to  November,  1892, 
when  she  was  readmitted  to  the  Presbyterian  Hospital, 
where  since  then  she  has  had  a  multiplicity  of  symptoms. 

Menstruation  Avas  normal  up  to  June,  1893.  In  July 
she  had  a  severe  attack  of  dysentery.  The  convales- 
cence was  slow,  and  she  was  left  very  anaemic,  the  blood- 
count  showing  as  low  as  581,000  red  cells  on  August 
1st  of  that  year.  On  September  1st  the  blood-count 
showed  950,000  red  cells  with  macrocytes,  microcytes, 
etc.  On  October  18th  the  red  cells  had  increased  to 
1,620,000.  The  patient's  condition  seemed  noAV  fairly 
good.  Her  color  had  returned  in  a  measure,  so  that  the 
outlook  seemed  more  encouraging.     There  was  no  men- 


MOTOR  ATAXIA.  135 

strual  flow  between  June  and  October,  in  which  latter 
month  she  had  a  slight  show,  which  recurred  again  in 
November,  but  never  since. 

By  January  1, 1894,  there  was  do  material  change,  save 
that  in  the  last  few  days  she  was  decidedly  more  anaemic 
again,  and  had  headache,  dyspnoea,  weakness,  and  palpita- 
tion of  the  heart  on  the  slightest  attempt  at  exertion,  with 
oedema  of  the  ankles  coming  on  late  in  the  afternoon. 
There  was  no  oedema  of  the  face.  The  skin  has  become 
of  a  lemon-yellow  color  and  the  conjunctivae  of  a  bluish 
tint.     Her  lips  are  almost  colorless. 

The  apex-beat  of  the  heart  is  in  the  fifth  interspace. 
No  thrill  is  felt.  The  shock  of  the  second  sound  is  readily 
felt  in  the  pulmonary  area.  The  area  of  cardiac  dulness 
is  normal.  There  is  a  soft,  hemic,  systolic  murmur,  low 
in  pitch,  transmitted  into  the  axilla,  accompanying  but  not 
obliterating  the  first  sound  at  the  apex.  There  is  also  a 
higher-pitched  systolic  murmur  (probably  hemic)  heard  in 
the  pulmonary  area. 

The  area  of  liver-dulness  is  slightly  increased.  There  is 
one  tender  spot  on  palpation  with  the  finger-tips  to  the 
right  of  the  median  line  two  inches,  and  another  two  and 
a  half  inches  above  the  umbilical  line.  On  January 
16th  the  patient  had  severe  pain  in  the  region  of  this  ten- 
der spot,  with  great  pallor  and  increasing  weakness,  so  much 
so  that  duodenal  ulceration  and  possibly  hemorrhage  were 
thought  of.  Dr.  Musser  had  the  stools  carefully  examined. 
No  blood  was  passed,  however,  and  no  parasite  could  be 
found  as  a  cause  of  the  severe  anaemia.  The  haemoglobin 
had  at  this  time  gone  down  to  15  per  cent.,  while  the  red 
blood-cells  numbered  930,000.  There  were  also  poikilo- 
cytes,  macrocytes,  and  microcytes  in  abundance,  while 
macroscopically  a  drop  of  blood  looked  like  slightly 
tinged  muddy  water. 

By    February    22d    the    patient's    skin    and    mucous 


136  NERVOUS  DISEASES. 

membranes  had  again  brightened.  Her  general  condition 
also  became  much  improved.  She  was  decidedly  less 
nervous,  and  sat  up  a  short  time  in  a  chair  each  after- 
noon, but  tired  easily  and  could  not  walk. 

On  admission  to  the  Infirmary,  March  2,  1894,  the  fol- 
lowing notes  were  made  as  to  her  condition :  She  is 
a  brunette,  fairly  Avell  nourished,  weighing  129  pounds. 
She  complains  of  a  feeling  of  "numbness  and  tingling  " 
in  her  hands  and  feet.  She  says  if  she  undertakes  to 
hold  anything  in  her  hands  she  must  see  it  in  order 
to  feel  sure  that  it  is  there.  She  can  feed  herself,  but  her 
hands  are  too  clumsy  to  permit  of  her  cutting  her  food.  She 
cannot  dress  her  hair.  She  can  button  her  night-dress, 
but  clumsily,  and  only  as  far  up  as  she  can  see  the  buttons. 
These  defective  acts  seem  to  be  all  due  to  awkwardness 
rather  than  to  actual  loss  of  tactile  sense,  which  seems  per- 
fect in  the  hands  and  fingers.  The  disorder  is  mainly  a 
motor  ataxia.  There  is  no  subjective  numbness  or  ting- 
ling anywhere  except  in  the  hands  and  feet.  She  does  not 
complain  of  headache.  She  has  pain  in  the  back  after  any 
exertion,  such  as  sitting  up.  She  can  stand  07ily  by  being 
supported  on  either  side  ;  she  takes  a  few  steps  while  being 
thus  held,  but  the  movements  are  markedly  ataxic.  The 
left  foot  is  pushed  forward.  The  right  one  is  thrown  up 
and  out  in  utter  incoordination. 

In  the  sitting  position,  unsuj^ported  and  with  eyes  closed, 
she  does  not  sway. 

Other  than  by  the  characteristic  gait,  ataxia  of  the  lower 
extremities  is  shown  by  an  inability  to  bring  the  heel  of 
either  foot  in  contact  with  the  opposite  instep.  Ataxia  of 
the  upper  extremities  is  shown  even  when  lying  by  inability 
to  bring  the  fingers  of  the  outstretched  hand  to  the  nose 
with  the  eyes  closed.  The  movements  of  the  lower  ex- 
tremities are  less  incoordinate  when  she  lies  supine. 

The  reflexes — plantar,  epigastric,   and   abdominal — are 


MOTOR  ATAXIA,  I37 

normal.  The  knee-jerks  are  also  normal  and  relnforcible. 
There  is  no  clonus.  There  is  absence  of  the  normal  ankle- 
jerks,  as  tested  by  tapping  the  tendo-Achillis,  but  they  can 
be  elicited  by  reinforcement.  The  elbow-jerks  are  normal 
and  reinforcible.  The  muscle-jerks  are  everywhere  normal 
and  reinforcible. 

Sensibility.  She  distinguishes  with  natural  competence 
the  two  points  of  the  gesthesiometer  Avhen  placed  on  the 
fingers,  and  points  out  quite  accurately  the  fingers  so 
touched.  There  seems  to  be  some  delay  in  decision. 
Tactile  sensation  on  the  palmar  and  dorsal  surfaces  of 
both  hands  is  normal.  The  thermal  sense  is  perfect.  As 
to  the  weight  (or  muscle)  sense,  on  holding  the  palm  of 
the  hand  out  (the  patient  being  blindfolded)  she  distin- 
guishes a  difference  between  the  following  weights — i.  e., 
' '  the  least  observable  difference  "  of  Weber's  law :'  The  right 
palm  distinguishes  one  ounce  from  two  ounces  only ;  the 
left  palm  tells  one-quarter  ounce  from  one-half  ounce.  Thus 
there  is  a  difference  in  muscle-sense  between  the  right  and 
left  arms,  and  the  perception  is  not  as  acute  as  it  should 
be.  Numbness  and  tingling  sensations  are  complained  of 
in  the  hands  and  feet.  No  such  parsesthesia  exists  in  other 
parts.  There  is  no  anaesthesia  or  hypersesthesia,  but  there 
is  varying  analgesia  to  a  deep  pin-prick,  as  follows :  The 
left  lower  extremity  is  analgesic  from  the  groin  to  the 

1  Weber  used  the  method  of  "  least  observable  differences  "  as  applied  to 
sensations  of  pressure  and  the  measurement  of  lines  by  the  eye,  but  Fechner 
expanded  it  and  assumed  that  all  just  observable  differences  are  equally 
great;  so  that  the  law  is  sometimes  called  "  Fechner's  law."  Expressed  in 
another  way,  the  results  depend  on  (1)  strength  of  stimuli ;  (2)  degree  of  ex- 
citability. If  two  is  constant  and  one  is  then  varied,  it  is  found  that  if  the 
stimulus  be  doubled,  trebled,  etc.,  the  sensation  only  increases  as  the  loga- 
rithm of  the  stimulus  (e.  g.,  stimulus  10, 100,  and  1000  times,  then  sensation 
increases  1,  2,  and  3).  There  is  a  lower  limit  of  excitation  liminal  intensity  and 
an  upper  limit  of  excitation  liminal  intensity.  Thus  above  this  no  appreciable 
increase  in  sensation  can  be  distinguished.  This  is  called  the  "  range  of  sen- 
sibility." Thus,  with  10  grammes  in  the  hand,  we  have  to  add  or  remove  3.3 
grammes  before  a  difference  in  sensation  is  perceptible.  In  100  grammes  we 
would  have  to  add  or  withdraw  33.3  grammes. 

12- 


1 38  ^^^  yO  us  DISEASES. 

metatarso-phalangeal  joints,  and  the  right  upper  extremity 
from  midway  between  the  shoulder  and  the  elbow  to  the 
metacarpo-phalangeal  joints.  The  condition  of  analgesia 
of  the  upper  extremity  is  variable,  however,  as  twenty-four 
hours  after  the  first  examination  sensation  to  pain  seemed 
almost  as  acute  as  upon  the  opposite  side.  The  right  leg 
and  thigh  are  at  times  partially  analgesic  to  a  pin-prick, 
but  the  areas  of  defect  vary  greatly  from  day  to  day. 

Dr.  Willits  reports  the  muscular  response  to  faradism 
everywhere  normal. 

Drs.  de  Schweinitz  and  A.  Thomson  made  the  following 
eye-report :  ' '  Both  discs  gray,  especially  in  the  deej^er 
layers.  Arteries  too  small,  veins  normal.  Pupils  normal. 
Color-fields  (red  and  blue)  typically  reversed.  Form-fields 
contracted." 

The  reaction-time  of  the  different  senses  was  next  inves- 
tigated. 

Mr.  Lightner  Witmer  kindly  made  examinations  of  this 
woman  for  me  at  the  Psychological  Laboratory  of  the  Uni- 
versity of  Pennsylvania,  on  jMarch  27,  1894,  from  which 
the  following  is  abstracted  : 

First,  as  regards  the  motor  nervous  system,  as  recorded 
on  the  chronoscope  (an  instrument  for  recording  the  ra- 
pidity of  a  motion).  It  was  found  that  to  pass  over  a  dis- 
tance of  50  cm.  it  took  the  right  hand  yV^^  ^^  ^  second 
(?'.  e,,  224  (t).  In  the  left  hand  y^Fo  ^^  ^  second  was  re- 
quired to  pass  as  quickly  as  possible  over  the  same  dis- 
tance. 

A  second  series  of  these  motor  impulse  experiments 
(made  after  all  the  reaction-time  experiments)  was  but 
little  lengthened  as  compared  to  the  first  series,  thus 
pointing  to  the  absence  of  fatigue  of  any  considerable 
amount. 

The  normal  rate  of  movemeut,  from  the  experiments  of 
Professors  Fullerton  and  Cattell,  varies  l)etween  87  o  to 


MOTOR  ATAXIA.  139 

180  (T  for  50  cm.,  as  recorded  on  the  chronoscope.  The 
woman's  movements  were  therefore  slow. 

The  reaction-time  to  sound  varied  from  ISla  to  .343  a, 
somewhat  longer  than  the  normal,  which  ranges  from 
120  a  to  170^. 

The  reaction-time  for  light  varied  from  160  (^  to  350  a. 
The  normal  light-perception  is  from  160  o-  to  200  ff. 

The  reaction-time  to  electric  shock  varied  from  200  <y  to 
476  a,  a  very  marked  retardation — and  this,  too,  while  the 
muscle-response  to  faradism  seemed  normal.  Here  is  one 
of  the  enigmas  appearing  in  this  curious  case. 

There  is  thus  a  general  tendency  to  slowness  of  percep- 
tion.    The  receptive  centres  have  at  least  become  dulled. 

The  patient's  general  health  is  fair.  All  organs  seem 
normal,  excepting  that  the  bowels  are  a  little  torpid.  She 
has  good  control  over  the  bladder,  and  analysis  of  the  urine 
is  negative.     Sleep  is  undisturbed. 

The  color  has  returned  markedly  since  January,  1894, 
the  red  blood-cells  numbering  3,200,000  and  not  being 
altered  in  shape  or  size.  The  haemoglobin-estimation  is 
60  per  cent.^ 

The  case  as  you  hear  it  must  strike  you  as  peculiar. 
Reading  this  story  backward,  so  to  speak,  the  paresis, 
the  anorexia,  the  type  of  mental  disorder,  all  point  to 
hysteria.  Then  we  have  added  a  dysentery,  which  leaves 
her  with  such  anaemic  conditions  and  accompaniments 
as,  for  a  time,  seem  to  make  the  diagnosis  of  added 
pernicious  anaemia  probable.  The  history  of  the  devel- 
opment of  the  remarkable  ataxia  is  not  complete,  but 
its  presence  is  to-day  her  most  obvious  symptom.    Note 


1  After  the  administration  of  pyrophosphate  of  iron  in  divided  doses  up  to 
95  grains  in  some  70  hours  the  blood-count  showed  increase  of  red  blood- 
corpuscles  to  4,160,000,  and  of  haemoglobin  to  70  per  cent.  See  Dr.  John  K. 
Mitchell's  paper  on  Blood-counts. 


140  ^'ER  VO  US  DISEASES. 

also  the  facts  of  varying  analgesia,  the  typical  changes 
in  the  color  fields,  the  equally  curious  alterations  in 
these,  and  you  have  before  you  a  case  of  hysteria  with 
the  very  unusual  additions  of  pernicious  anaemia  and 
ataxia  of  motion. 

As  you  see  her  walk,  with  the  aid  of  two  nurses,  she 
usually  lifts  the  feet  high,  and  throws  them,  so  to  speak, 
in  a  disorderly  way.  AVith  shut  eyes  her  motions  are 
all  worse,  as  you  may  perceive  when  the  ataxic  hand- 
movements  are  thus  studied.  You  Avould  have  no 
doubt,  at  sight,  of  hers  being  a  case  of  typical  posterior 
sclerosis,  and  still  less  doubt  if  you  recall  the  fact  that 
she  cannot  tell  the  difference  as  between  the  weight  of 
a  penny  and  that  of  a  silver  dollar.  The  exact  facts 
are  better  related  in  the  case-notes.  Apparently  she 
has  more  or  less  defect  of  the  sense  of  amount  of  mus- 
cular exertion  put  forth — loss  of  muscle-sense. 

Xaturally,  I  look  with  suspicion  on  an  hysterical 
woman  long  in  hospital  wards;  but  as  to  the  facts 
I  have  stated  I  do  not  think  we  were  deceived.  I 
shall  presently  return  to  this  matter  of  loss  of  muscle- 
sense. 

Considering  the  case  as  ataxic,  such  as  we  see  here 
at  every  clinic,  you  should  be  surprised  to  find,  as  I 
now  show  you,  that  we  have  normal  knee-jerks,  elbow- 
jerks,  and  muscle  jerks,  and  also  normal  reiuforcements. 
The  responses  are  not  spastic,  and  the  limbs  are  not 
like  those  of  people  witli  lateral  columnar  disease  and 
''lead-pipe'^  passive  flexion.  There  is  no  clonus;  I 
can  get  no  ankle-jerk  by  a  blow  on  the  tendo-Achillis, 
or  on  the  sole  of  the  foot.  I  can  call  out  this  response 
by  motor  or  sensory  reinforcement.  But  for  this  re- 
markable exception  I  should  have  almost  no  indecision 


MOTOR  ATAXIA.  141 

as  to  how  to  characterize  this  deeply  interesting  case. 
Perhaps  I  should  not  give  too  much  importance  to  the 
partial  loss  of  ankle-jerk,  especially  in  a  case  so  pro- 
foundly hysterical.  Is  this  case,  then,  an  hysterical 
ataxia  due  to  hysterical  loss  of  muscle-sense?  That 
this  should  be,  along  with  preservation  of  muscle- 
reflexes,  and  with  no  loss  of  tactile  sense,  and  only 
variable  cutaneous  analgesia,  would  be  interesting  and 
unusual,  and,  let  me  admit,  a  little  puzzling.  Hysteria 
confuses,  but  does  not  exclude  organic  spinal  mala- 
dies, and  the  partial  loss  of  the  lowest  muscle-reflex  is 
suspicious.  But  there  are  no  other  signals  of  poste- 
rior sclerosis:  no  pain,  no  reflex  losses  in  the  ataxic 
arms,  no  eye-signs. 

Briquet,  whose  pictures  of  hysteria  look  to  me  a  little 
too  vivid,  described  a  form  of  ataxia  due  to  loss  of 
both  skin-sense  and  muscle-sense.  He  seems  to  think 
that  the  loss  of  the  latter  is  not  to  be  met  with  until 
the  former  has  become  positive.  With  this  double  loss 
comes  incapacity  to  eifect  a  motor  purpose  without 
seeing  the  acting  member.  With  view,  he  says,  the 
muscular  acts  are  perfect.  This  is  not  the  case  in  our 
patient;  nor  do  I  think  it  ever  is  in  these  cases  pre- 
cisely as  he  states  it.  The  sight  helps  the  true  hysterical 
ataxic,  but  does  not  enable  her  to  attain  ease  and  per- 
fection in  her  acts. 

The  interest  of  our  own  case  lies  in  the  isolated  loss 
of  pain-sense,  without  corresponding  absence  of  cuta- 
neous tactile  sense.  I  have  often  seen  more  or  less 
surface-anaesthesia  with  more  or  less  or  no  loss  of 
muscle-sense.  The  great  defect  of  this  latter  seen  in 
our  present  case,  Avithout  any  notable  tactile  loss,   is 


142  NERVOUS  DISEASES. 

more  than  merely  uncommon.  Again,  with  the  ataxia 
and  failure  to  estimate  differences  in  weights,  we  have 
complete  muscle-reflexes. 

Case  XLVI. — In  the  same  ward  is  a  girl  of  twenty-two 
years,  who  has  the  more  common  form  of  hysterical  ataxia 
which  I  described  many  years  ago.  She  is  now  nearly 
well,  but  a  month  ago  her  walk  was  a  thing  most  interest- 
ing to  see.  She  walked  as  a  jointed  doll  endowed  with 
life  might  walk — a  succession  of  jerky,  abruptly  ended 
movements,  with  sway  of  head  and  body  back  and  front 
or  to  right  and  left.  For  a  fuller  account  I  refer  you 
to  my  original  delineation  of  this  singular  form  of  dis- 
order. 

The  patient  was  put  alone  in  a  room,  given  very  decided 
faradic  currents  to  the  muscles  with  the  wire  brush  on  a 
dry  skin,  and  daily  full  massage,  with  iron  and  arsenic. 

She  has  been  rapidly  improving.  At  first,  to  aid  her 
steps,  she  used  the  device  1  described  long  ago  as  crutch- 
canes  :  but  she  can  now  walk  unaided ;  she  has  deserted 
her  bed  ;  knits  and  sews,  and  seems  a  prosperous  case. 

April  23,  1894.  Her  station  is  good  with  closed  eyes. 
Sensation  is  now  normal  in  all  forms,  and  the  obvious  de- 
lay in  perception  exists  no  longer.  She  can  walk  clumsily 
some  twenty  feet  unaided. 

Up  to  May  20th  my  records  describe  increasing  gain. 
She  walks  a  few  steps  unaided,  but  still  prefers  to  help  her- 
self with  the  crntch-canes.  She  was  rarely  in  bed ;  knitted, 
sewed,  and  used  scissors. 

At  this  time  her  station-sway  with  closed  eyes  was  hardly 
more  than  normal. 

Soon  after  I  left  my  service,  in  early  June,  the  knee- 
reflexes  began  to  grow  less  and  less  responsive,  and  the 
blood-counts  fell  to  1,600,000,  the  haemoglobin  to  20  per 
cent. 


MOTOR  ATAXIA.  143 

September  1,  1894,  she  died.  I  add  Dr.  Burr's  post- 
mortem notes  : 

"At  post-mortem  I  found  quite  marked  emaciation.  Skin 
lemon-yellow.  Subcutaneous  fat  small  in  amount,  orange- 
yellow  in  color.  Muscles  very  dark  red.  Blood  liquid 
throughout  the  body.  Heart  normal  in  size ;  cavities 
contain  a  little  semifluid  blood  ;  Avails,  average  thickness; 
muscle  brownish  ;  very  slight,  old  thickening  of  mitral 
valves.  Liver  slightly  fatty.  Lungs,  kidneys,  and  spleen 
showed  nothing  noteworthy.  No  gastric  atrophy.  Tibial 
marrow  currant-jelly  color,  broken-down,  cancellated  bone 
tissue.  Many  nucleated  red  corpuscles.  Cerebral  mem- 
branes and  brain  normal ;  spinal  membranes  normal.  On 
cross-section  of  the  spinal  cord  the  posterior  columns  are 
pearly  gray. 

^'Microscopical  examination,  highest  level  of  cervical  cord. 
Very  marked  degeneration  of  the  posterior  columns,  ex- 
cept a  narrow  level  along  the  edge  of  the  gray  matter. 
In  the  lateral  columns  in  the  region  of  the  crossed  pyram- 
idal tracts,  but  not  confined  strictly  to  them  and  not  in 
contact  with  the  posterior  gray  matter,  is  an  area  of  much 
slighter  but  still  quite  marked  degeneration.  Running 
round  the  periphery  of  the  lateral  columns  and  reaching 
quite  far  forward  is  an  irregular  band  of  not  very  marked 
degeneration.  The  intensity  of  the  lesion  varies  much. 
It  is  patchy,  greater  here,  less  there.  The  remainder  of 
the  white  matter  and  the  gray  matter  normal.  Peripheral 
nerve-roots  normal.     No  meningitis. 

'' Cervical  swelling.     The  same  condition  obtains. 

"  Upper  dorsal  region.  The  condition  is  the  same,  except 
that  the  band  of  healthy  tissue  between  the  gray  matter 
and  the  posterior  columns  is  wider  and  there  are  quite  a 
number  of  healthy  fibres  in  the  periphery  of  the  latter. 
Marked  degeneration  of  the  crossed  pyramidal  tracts. 
Cerebellar  tract  fairly  normal. 


1 44  J^ER  VO  US  DISEASES. 

"Loiver  dorsal  region.     The  same. 

"Lumbar  swelling.  Slight  degeneration  of  the  postero- 
internal column  ;  very  slight  of  postero-external.  A  small 
area  of  degeneration  in  the  crossed  pyramidal  tract. 

''Histological  examination.  There  is  a  very  fine  and  very 
dense  network  of  connective  tissue.  No  increase  of  blood- 
vessels and  slight  thickening  of  their  walls.  There  is  no 
histological  difference  between  the  lesion  in  the  posterior 
and  that  in  the  lateral  columns.  Median  and  sciatic 
nerves  normal." 

To  sum  up,  here  is  a  case  of  hysteria  on  which  are 
grafted  later  the  typical  symptoms  of  pernicious  anae- 
mia with  its  ordinary  deceitful  rise  and  fall  of  blood- 
counts.  At  an  uncertain  period  we  have  the  further 
addition  of  an  aberrant  type  of  locomotor  ataxia  due 
to  organic  disease  of  the  cord.  The  changes  for  the 
better  in  the  way  of  motion  and  loss  of  analgesia  were 
due  to  an  improvement  in  the  group  of  hysterical 
symptoms. 

I  shall  rarely  be  able  to  show  you  so  interesting  an 
example  of  the  combination  of  three  distinct  maladies, 
nor  of  the  diagnostic  confusion  w^hich  grave  hysteria 
brings  into  the  study  of  organic  disease.  Looking 
back,  the  case  appears  plain  enough. 


CHAPTER  yill. 

POST-HEMIPLEGIC  PAIN;  PRE-HEMIPLEGIC  PAIN; 
POST-HEMIPLEGIC  DISEASE  OF  JOINTS;  POST- 
HEMIPLEGIC   NODES. 

There  is  some  danger  lest  amid  the  attractive  fas- 
cinations of  novel  bacteriological  study  we  may  lose 
sight  of  the  more  every-day  need  for  incessant  clinical 
watchfulness  as  to  the  lesser  symptomatic  novelties 
which  are  yet  to  be  detected.  The  case  which  I  show 
you  to-day  may  very  well  illustrate  my  meaning. 
It  is  of  considerable  interest  on  account  of  the  early 
date  at  which  joint-disorder  followed  an  attack  of  hemi- 
plegia. I  shall  presently  speak  to  you  further  of  its 
nature  and  explanation.  It  reminds  me  to  ask  your 
attention  to  pain  as  among  the  occasional  prodromes 
and  sequels  of  hemiplegia;  also  to  a  somewhat  novel 
matter — the  nodes  which  occasionally  appear  as  sequelae 
of  this  paralysis. 

The  late  Prof.  John  K.  Mitchell  first  called  attention, 
in  1831,  to  the  production,  through  spinal  injury  and 
sequent  disease,  of  joint-lesions  often  distinguishable 
with  difficulty  from  the  lesions  of  rheumatism.  Alli- 
son, in  1838,  described  joint-lesions  following  hemi- 
plegia. Drs.  Morehouse,  Keen,  and  myself  reported 
numerous  examples  of  joint-trouble  caused  by  periph- 
eral nerv^e-lesions,  and  since  then  I  and  otliers  have 
added  largely  to  the  literature  which  deals  with  nutri- 
tive changes  occasioned,  early  or  late,  by  cerebral  and 

13 


146  ^J^R  VO  US  DISEASES. 

spinal  disease,  and  by  the  diseases  or  traumas  of  nerve- 
trunks. 

It  is  noAV  generally  admitted  that  the  joint-disorders 
which  occasionally  follow  hemiplegia  from  cerebral 
lesions  owe  their  origin  to  a  descendino;  deo^enerative 
change  involving  the  motor  tract  and  finally  the  cord. 
If  this  be  so,  we  must  also  admit  that  these  changes 
are  in  certain  cases  very  rapid,  as  I  have  noAV  seen 
at  least  four  cases,  all  of  right-sided  cerebral  lesion, 
in  which  one  or  more  joint-lesions  followed  within 
four  days.  Then  there  is,  too,  a  small  group  of  cases 
not  alluded  to  in  the  books,  in  which  the  sequence  is 
as  follows: 

1.  Primarily,  unilateral  pain  in  muscular  or  fibrous 
tissues  and  great  soreness. 

2.  Tenderness  of  certain  joints,  slight  swelling,  and 
pain  on  only  one  side.  Repeated  attacks  strictly  limited 
to  one  side. 

3.  Subsequent  cerebral  clot  and  paralysis  of  the  pain- 
ful side. 

4.  Increase  of  joint-lesions  on  the  palsied  side  alone, 
and  generally  chronic  unilateral  joint-trouble. 

Another  type,  which,  like  this,  gives  us  occasion 
enough  to  reflect,  is  this: 

1.  Long-continued,  or  occasional,  muscular  aches  on 
one  side  only,  without  heart-disease  or  gout,  and  with 
no  joint-troubles. 

2.  After  a  year  or  two  paralysis  of  the  side  thus 
previously  affected. 

3.  Secondary  joint-lesions  on  the  same  side,  becoming 
chronic. 

In  a  third  class,  which  is  somewhat  rare,  we  have  as 
an  immediate  prodrome  of   hemiplegia   acute  pain    in 


HEMIPLEQIC  DISORDERS.  147 

the  muscular  masses,  so  as  to  be  taken  for  muscular 
rheumatism,  but  confined  to  the  side  which  within  forty- 
eight  hours  becomes  hemiplegic.  The  following  brief 
case-sketches  may  answer  for  illustrations: 

Case  XL VII. — C.  S.,  aged  fifty-two  years,  a  house- 
keeper, in  general  good  health  and  free  from  cardiac, 
renal,  or  gouty  troubles,  was  attacked  in  1880,  in  the 
early  spring,  with  pain  and  soreness  in  the  shoulder-muscles 
and  in  the  thigh  of  the  right  side.  The  attack  was  sharp, 
but  lasted  only  a  week.  It  was  repeated  a  month  later, 
and  again  and  again,  with .  more  or  less  swelling  and 
tenderness  of  the  shoulder,  finger-joints,  and  knee  on  the 
right  side  only.  The  last  two  attacks  were  accompanied 
with  headache  and  slight  vertigo.  The  final  attack  was 
limited  to  severe  ache  in  the  arm  and  leg,  and  after  three 
days  of  great  pain  there  was  sudden  loss  of  power  of  the 
whole  right  side,  with  loss  of  sensation.  This  last  was 
brief ;  but  the  motor  loss  was  more  grave,  and  there  was 
never  entire  recovery  of  motion  in  either  leg  or  arm.  On 
the  fifth  day  the  shoulder  became  swollen  and  tender,  and 
a  week  later  several  of  the  finger-joints  suffered  in  like 
manner  and  finally  the  knee.  There  was  early  and,  at 
last,  late  rigidity  of  the  arm-muscles.  None  of  the  joints 
got  well.  All  passed  into  a  state  of  subacute  inflam- 
mation, and  death  followed  a  second  hemorrhage  within 
eighteen  months. 

In  this  case  the  joint-lesions  were  seen  before  and  also 
after  the  cerebral  lesion. 

Case  XLVIII. — M.,  aged  sixty-four  years,  a  physician, 
was  well  as  to  heart,  kidneys,  and  arteries,  which  to  ap- 
pearance were  unusually  free  from  disease.  For  two  years 
before  his  paralysis  he  was  subject  to  nearly  constant  pain 
in  the  muscles  of  the  right  arm  and  leg  ;  occasionally,  but 
rarely,  he  had  slight  pain  in  the  right  knee-  and  shoulder- 


148  NERVOUS  DISEASES. 

joints  ;  none  in  the  smaller  articulations.  Occasionally 
the  pain  was  so  severe  in  all  of  the  right-side  muscles  of 
limbs  and  trunk  as  to  confine  him  to  his  bed  for  a  week. 
There  was  never  pain  on  the  left  side. 

In  June,  1859,  a  violent  bout  of  pain,  still  only  on  the 
right  side,  was  followed  on  the  second  day  by  sudden  and 
incomplete  loss  of  use  of  the  right  leg  and  arm,  without 
disturbance  of  consciousness  or  of  sensation.  Within  the 
next  three  years  he  had  three  attacks  of  hemiplegia,  none 
severe,  but  each  of  them  preceded  by  a  similar  onset  of 
muscular  pain  and  tenderness.  He  finally  died  of  pneu- 
monia. 

I  saw  many  years  ago  a  middle-aged  woman,  who  was 
seized,  w^ithout  known  cause,  with  violent  pain  in  the 
right  arm  and  leg.  There  were  no  joint-lesions.  The 
pain  was  agonizing.  Within  thirty-six  hours  she  had 
a  quite  complete  attack  of  hemiplegia  on  the  same  side, 
after  which  the  pain  slowly  faded  away  and  never 
returned.  She  made  a  good  recovery  and  died,  years 
after,  of  lung-disease. 

I  could  readily  add  to  these  cases.  To  observe  one- 
sided pain  or  joint-lesions  as  prodromes  or  remote  ante- 
cedents of  cerebral  lesions  is  not  exceedingly  rare.  I 
have  seen  one  such  case  within  a  year,  and  in  it  the 
muscular  pain,  as  is  not  uncommon,  slowly  passed  away 
with  the  paralysis. 

It  is,  of  course,  easy  to  dismiss  these  as  cases  of  the 
coincidental  occurrence  of  rheumatism  and  brain-lesions; 
but  this  will  hardly  satisfy  the  modern  clinical  observer. 
Certainly  they  should  suggest  inquiry  as  to  whether  or 
not  incipient  brain-lesions,  finally  productive  of  paral- 
ysis, may  not,  either  directly  or  through  an  influence 


HEMIPLEGIC  DISORDERS.  149 

on  the  cord,  occasion  morbid  phenomena  simulating 
rheumatic  symptoms. 

It  is  conceivable  that  the  many  cases  I  have  seen 
may,  one  and  all,  represent  the  coincidental  occur- 
rence of  unilateral  rheumatism  with  a  sequence  of 
hemiplegia.  But  there  is  another  explanation  which 
is  possible,  and  for  this  reason  I  desire  to  call  attention 
anew  to  the  antecedents  and  consequences  of  certain 
hemiplegias.  If,  as  I  and  others  have  seen,  inflamed 
joints  may  follow  within  from  one  to  four  days  upon 
hemiplegias,  it  seems  unlikely  that  their  presence 
can  be  due  to  organic  spinal  changes,  or  to  these 
alone,  unless  these  changes  be  far  more  rapid  than  we 
at  present  conceive  them  to  be.  If  they  are  due  directly 
to  the  immediate  influence  of  the  brain-lesion  or  to  its 
effects  on  the  yet  unaltered  cord,  then  even  the  joint- 
lesions,  which  are  more  remote  in  time,  may  have  a 
like  origin.  Really,  it  does  not  as  yet  seem  to  be  quite 
sure  that  the  cord  is  always  or  alone  responsible,  or  that 
the  joint-troubles  as  well  as  the  pain  may  not  have 
their  primary  origin  in  the  cerebral  centres.  And  at 
all  events  we  need  careful  study  of  the  motor  tracts  in 
cases  of  early  death  from  cerebral  disease. 

Another  rare  consequence  of  hemiplegia  is  the,  as 
yet,  undescribed  occurrence  of  nodes  of  the  periosteum. 
These  still  further  add  to  the  rheumatic  picture  pre- 
sented by  certain  palsied  limbs.  I  speak  of  these  nodes 
as  being,  so  far,  undescribed,  for  in  a  wide  search  I 
find  no  mention  of  them,  and  they  appear  thus  far  to 
have  escaped  the  attention  of  clinical  observers. 

I  first  saw  them  some  years  ago  in  a  workman  about 
forty-five  years  old.     He  was  a  plumber,  but  had  no 

13- 


1 50  ^EB  VO  US  DISEASES. 

evidence  of  lead-poisoning,  which,  in  fact,  is  scarcely 
ever  seen  in  this  class  of  mechanics.  The  patient 
had  never  had  any  genital  malady,  and  was  in  good 
health  until  he  had,  after  overwork  in  hot  weather,  an 
attack  of  left  hemiplegia.  Unconscious  for  a  day,  he 
made  a  fair  recovery,  except  as  to  his  arm,  in  which 
during  two  or  three  months  developed  late  rigidity  and 
joint-lesions.  The  knee,  which  is  rarely  affected,  suf- 
fered, although  slightly.  In  examining  with  care  the 
state  of  this  man's  joints  I  found,  about  three  inches 
above  the  ankle,  an  elongated,  very  tender  node  about 
an  inch  wide,  and  at  the  insertion  of  the  deltoid  a  sec- 
ond, still  more  prominent.  Interested  in  these  lesions, 
I  asked  Dr.  Maury,  as  an  expert  in  syphilis,  to  ex- 
amine the  case.  He  came  to  the  conclusion  that  there 
were  no  evidences  of  this  malady,  which,  I  may  add, 
the  man  positively  denied  having  ever  had.  A  long 
and  active  course  of  treatment  with  iodides  and  mer- 
cury failed  to  alter  the  nodes  in  the  least  degree,  and  I 
came  at  last  to  the  conclusion  that,  like  the  joint-lesions, 
they  were  indirectly  the  offspring  of  the  cerebral  malady. 
I  have  since  then  seen  similar  cases,  but  of  these  I  have 
no  notes. 

The  case  I  now  show  you  came  first  under  notice  in 
1891,  and  is  the  earliest  example  of  joint-lesion  fol- 
lowing hemiplegia  which  I  have  ever  met  with.  It 
also  shows  to  this  day  the  interesting  nodes  to  which 
I  desire  to  call  attention: 

Case  XLIX. — G.  AY.,  aged  fifty-eight  years,  is  a  manu- 
facturer in  active  business,  of  good  health  and  habits. 
He  indulges  in  moderation  as  to  wine  and  tobacco.  He 
has  never  had  syphilis,  and  there  is  no  obvious  disease 
of   the  heart  or  vessels,  and  no  renal  disorder.      He  is 


HEMIPLEGIC  DISORDERS.  151 

subject  at  times,  for  a  week  or  more,  to  deposits  of  urates  in 
the  urine  passed  at  night.  On  July  20,  1891,  after  a 
severe  mental  and  moral  strain  which  necessarily  lasted 
during  four  hours,  he  went  to  a  friend's  house  to  rest. 
As  he  was  about  to  lie  down  he  reeled  and  fell.  The 
left  arm,  on  which  he  leaned  against  the  bed,  was  some- 
what twisted,  and  possibly  strained,  as  he  fell.  He  was 
found  unconscious,  and  with  complete  paralysis  of  the 
left  side.  In  twenty-four  hours  he  was  conscious  of 
his  surroundings.  His  speech  was  long  affected,  and  the 
tongue  was  protruded  far  to  the  left.  The  leg  recov- 
ered fairly  well,  but  when  first  seen  by  me — November 
10,  1891 — the  foot  still  dragged  a  little ;  the  left  arm  was 
helpless. 

The  day  after  the  paralysis  he  felt  pain  in  the  shoulder 
and  down  the  outside  of  the  arm.  From  this  date  he  had 
increasing  pain,  swelling,  and  tenderness  in  this  joint.  In 
August  the  elbow  became  painful,  and  early  in  September 
all  the  joints  of  the  left  hand  were  inflamed.  There  was 
early  rigidity,  and,  later,  extreme  rigidity,  with  violent  con- 
traction of  the  forearm-muscles,  so  that  the  nails  indented 
the  palm.  There  had  been  little  gain  as  to  these  symp- 
toms, but  the  pain  has  become  less  severe.  At  the  deltoid 
insertion  a  node,  three  inches  by  one,  of  irregular  form 
and  quite  prominent,  could  be  felt.  It  was  plainly  peri- 
osteal and  painful  in  varying  degrees.  On  the  ulna, 
above  the  wrist,  was  a  second  node,  and  above  it  a  smaller 
one,  both  very  distinct  and  also  tender. 

The  foot  was  somewhat  contracted.  All  the  nails  on  the 
palsied  side  grew  very  slowly  for  two  months.  Sensation 
was  slightly  defective  as  to  touch  only  on  the  palmar  faces 
of  the  first  and  second  digits. 

The  tongue  was  protruded  to  the  left,  and  speech  was 
not  quite  perfect. 

When  seen,  in  May,  1892,  there  was  less  pain,  but  all 


1 52  NEB  VO  US  DISEASES. 

of  the  joints  of  the  left  arm  were  tender,  swollen,  and  use- 
less. 

The  nodes  are  still  to  be  felt,  although  they  vary  in  size, 
and  are  at  times  larger  than  now. 

This  case  is  to  me  very  interesting.  It  is  possible 
that  the  shoulder-joint  may  have  been  twisted  in  the 
fall,  and  that  this  accounts  for  the  very  early  inflamma- 
tion, which,  later,  may  have  owed  its  continuance  to  the 
paralysis.  I  have,  how^ever,  seen  one  case  in  which  the 
joint-lesion  came  on  within  thirty- six  hours,  and  other 
cases  in  which  it  came  on  within  four  days.  Therefore, 
it  is  possible  that  in  the  present  example  the  shoulder- 
trouble  may  have  been  the  immediate  offspring  of  the 
brain-lesion  alone. 

The  mechanism  of  the  production  of  these  very  com- 
mon incidents  of  hemiplegia  is  still  a  difficult  question. 
Perhaps  a  careful  study  of  the  post-mortem  chemical 
state  of  the  limbs  may  help  us ;  but  it  should  be  made 
immediately  after  death.  It  is  quite  possible  that  the 
nutritive  disturbances  of  a  palsied  limb  may  evolve, 
locally,  products  which  give  rise  to  these  pseudo-rheu- 
matic appearances.  Peripheral  nerve-lesions  clearly 
alter  the  skin-secretions,  as  I  have  elsewhere  shown, 
and  they  may  as  likely  evolve  within  the  limb  chemical 
products  favorable  to  the  evolution  of  joint-disease.  It 
is  not  enough  to  say  that  this  is  caused  by  altered  nu- 
trition. The  nodes  I  describe  are  also  one  more  addi- 
tion to  the  points  of  clinical  resemblance  between  a 
palsied  and  a  rheumatic  limb,  and,  small  as  is  their 
mportance,  it  is,  I  tliink,  of  value  to  note  their  occa- 
sional presence. 

AMien   acute  unilateral    pain    immediately  precedes 


HEMIPLEGIC  DISORDERS.  I53 

hemiplegia  of  the  same  side,  such  a  sequence  should 
lead  us  to  reconsider  the  more  doubtful  instances  in 
which  pain  and  joint-lesions  more  remotely  but  more 
continuously  antedate  the  palsy.  I  have  myself  no 
doubt  that  pain  and  many  other  sensations  may  be  of 
cortical  and  cerebral  origin/ 

1  Note  an  interesting  paper  on  Brain-itch,  by  Dr.  Bremer,  of  St.  Louis. 
Review  of  Insanity  and  Nervous  Diseases,  December,  1892. 


CHAPTER   IX. 

THE   TREATMENT    OF   SCIATICA. 

I  PROMISED  that  these  clinical  lessons  should  some- 
times consider  for  you  such  peculiar  therapeutic  methods 
as  are  in  use  within  our  walls.  Accordingly^  I  call 
your  attention  to-day  to  certain  points  in  the  diagnosis 
and  treatment  of  sciatica. 

Under  this  name  the  books  include  true  neuralgia, 
without  demonstrable  organic  changes  in  the  nerve,  and 
the  graver  pain  Avhich  is  due,  as  a  rule,  to  some  grade 
of  neuritis. 

Let  us  admit  that  the  first  class  is  seen  in  practice  in 
all  degrees,  has  a  great  variety  of  parentage,  and  at 
times  many  parents,  or  haply  none  that  can  be  found. 

To  men  like  you,  advanced  students,  clinically  watch- 
ful, it  is  needless  to  say  that  the  milder  sciatic  neural- 
gias are  sometimes  of  malarial,  gouty,  rheumatic,  syph- 
ilitic, ansemic,  or  other  origin — mere  functional  dis- 
orders like  the  typical  fifth-nerve  neuralgia.  Be  this  as 
it  may,  I  am  sure  that  sciatic  pains,  whatever  be  their 
cause,  are  likely  to  become  permanent  and  to  pass  into 
distinct  forms  of  organic  disease  of  the  sheaths,  and, 
at  last,  into  neuritis,  w^ith  degenerative  changes  in  the 
nerve-tissue.  Too  often  you  can  detect  no  distinct 
cause,  or  find  that  you  must  fall  back  for  explanation 
on  a  general  lowering  of  tone,  or  on  relatively  slight 
anaemia,  or  something  as  trivial  in  appearance.  The 
unusual  causes,  the  distant  reflex  parentage,  like  the 


THE  TREATMENT  OF  SCIATICA.  155 

luckily  discovered  decayed  tooth  of  fifth-nerve  neural- 
gia, are  rarely  called  on  to  explain  sciatica.  Tliey 
serve  at  best  to  keep  us  watchful  and  to  make  the  text- 
books less  dull  reading  by  introducing  the  pleasant  un- 
expectedness of  romance. 

I  pause  here  to  urge  on  you  the  fact  that  every  human 
being  has  a  different  standard  of  resistance  to  the  effects 
of  anaemia,  malaria,  or  any  of  the  varied  forms  of 
blood-defect  or  mal-assimilation.  AYhat  does  not  de- 
press one  is  serious  for  another.  Also,  I  ask  you  again 
to  remember  that  frequently  a  neuralgia  has  many 
parents.  Overwork,  overworry,  or  a  hemorrhage  may 
cause  anaemia,  and  out  of  this  may  come  functional 
gastro-intestinal  failures,  and  these  in  turn  may  occasion 
lithsemic  disturbances,  or  make  available  for  mischief 
the  effects  of  exposure  or  accident. 

Possibly,  at  times,  old  and  long  latent  syphilis,  or 
even  gout,  is  answerable.  Such  a  case  meets  with  a 
fall  on  the  buttocks,  and  thus  acquires,  owing  to  the  con- 
stitutional poisoning  of  the  patient,  capacities  to  develop 
an  obstinate  neuritis.  The  type  and  severity  depend 
upon  the  hygienic  surroundings  and  the  past  history. 
An  English  writer  declares  that  he  has  never  seen  caus- 
algia  such  as  we  saw  from  1861  to  1864,  nor  have  I  so 
seen  it  since,  because  men  worn  out  with  marching, 
soaked  with  malaria,  and  exhausted  by  exposure  and 
diarrhoea,  are  not  now  the  subjects  of  wounds  from 
Minie-balls. 

For  the  unthoughtful  there  is  only  the  final  accident; 
for  the  man  who  thinks  there  is  link  on  link  of  the 
chain  of  preparatory  states,  and  it  were  easy  to  illus- 
trate them  further.  This  is,  however,  to  be  only  a 
lesson  of  hints,  and  I  pass  on. 


156  ^^ER  VO  us  DISEASES. 

Before  considering  the  ordinary  sciaticas  I  pause  to 
say  a  word  as  to  sciatic  pain  of  which  the  cause  is 
organic  and  lies  within  the  pelvis.  You  cannot  be  too 
watchful  as  to  this  source  of  trouble.  When  you  find 
extravagant  pain  down  the  nerve  be  careful  how  you 
decide.  Sciatic  neuritis  is  a  very  painful  malady,  but 
the  pain  caused  by  the  squeeze  and  inflammation  of 
rapid  intra-pelvic  carcinoma  is  a  far  more  terrible  thing, 
and  the  grade  of  pain  may  help  you  in  your  decision. 
In  any  case  of  doubt  the  rectal  examination  should  be 
thorough. 

Several  times  in  my  life  I  have  seen  the  causal  diag- 
nosis of  a  furious  sciatica  made  on  the  post-mortem 
table  by  the  discovery  of  a  saddle-like  growth  astride 
of  the  cords  of  the  parent  plexus.  If  the  tumor  be 
small,  palpation  is  useless  as  a  guide,  and  the  best  of 
us  may  be  baffled.  At  times  a  large  growth  rewards 
our  search.  Twice  I  iiave  seen  accumulations  of  feces 
give  rise  to  irritative  pressure:  one  got  well;  but 
one,  which  had  been  treated  for  multiform  malignant 
tumors,  was  so  regarded  up  to  death  and  perished 
miserably.  The  post-mortem  section  showed  enormous 
fecal  accumulations  of  such  hardness  as  caused  one 
of  the  assistants  to  think  they  were  masses  of  calculi. 
In  this  case  the  pain  was  in  the  right  sciatic  nerve. 

Benign  tumors  or  growths  of  syphilitic  origin  may 
act  within  the  pelvis  to  cause  sciatic  pain,  as  the  follow- 
ing interesting  case  serves  to  show: 

Case  L. — L.  B.,  aged  forty  years,  a  planter,  states  that 
sixteen  years  ago  he  had  a  sore,  then  said  to  be  syphilitic. 
He  has  had  no  secondaries  of  which  he  was  ever  aware, 
but  has  all  his  life  been  subject  to  herpetic  eruptions  on 
the  glans  penis.     He  has  been,  over  and  over,  pronounced 


THE  TREA  TMENT  OF  SCI  A  TIC  A .  157 

free  from  specific  disease.  In  August,  1891,  he  began 
to  have  vague  aches  in  the  occiput,  the  right  knee,  and 
the  thigh.  In  September  he  had  pain  in  and  about  the 
sciatic  notch  and  down  the  leg.  These  aches  became 
worse,  especially  below  the  knee,  and  at  last  almost  de- 
prived him  of  the  power  to  stand  or  walk.  At  night, 
after  twelve,  his  pain  was  so  intense  that  morphia  became 
essential.  His  case  on  entry  here  was  too  easily  taken  for 
granted  by  me  as  an  ordinary  neuritis,  and  subjected  to 
the  usual  treatment.  When  this  entirely  failed  I  began 
to  suspect  that  Ave  Avere  dealing  with  sciatica  of  an  unusual 
type.  In  making  the  re-examination  which  this  suspicion 
caused  me  to  undertake  I  found  at  the  middle  of  the  right 
thigh  a  smooth  swelling  of  the  bone.  If,  as  seemed  likely, 
this  was  a  node  and  specific,  it  became  clear  that  it  Avas  in 
no  A\  ay  competent  to  cause  the  pain ;  but  it  AA^as  as  clear 
that  there  might  be  Avithin  the  pelvis  or  at  the  notch  a 
similar  growth,  so  placed  as  to  compress  and  irritate  the 
great  sciatic.  One  Aveek  of  full  treatment  by  iodides  led 
to  rapid  lessening  of  the  external  node  and  to  a  SAvift  ex- 
tinction of  the  pain.  My  inference  was  probably  correct. 
After  a  fcAV  Aveeks  he  AA^as  dismissed  cured. 

It  is  also  well  to  remind  you  that  childbed  may  cause 
sciatica.  I  kncAV  many  years  ago  of  one  woman  avIio 
always  suffered  during  three  Aveeks  after  labor  witli 
double  sciatic  pain,  and  at  last,  after  a  labor  in  which 
there  Avas  profuse  flooding,  Avas  afflicted  Avith  a  left- 
sided  sciatica  for  many  months.  Some  pain  in  these 
nerves  you  will  all  hear  about  in  childbeds,  and  I  may 
add  that  to  strain  at  stool  may  cause  increase  of  suffer- 
ing to  a  patient  tormented  by  sciatica,  and  CA-en  to  rheu- 
matic people  Avho  are  Avithout  distinct  neuritis. 

I  am  quite  sure  that  some  Avomen  suffer  more  than 
do  others  in  childbed  from  this  effect  of  pressure  by  the 

14 


158  NEB  VO  US  DISEASES. 

descending  head.  For  this  there  may  be  a  reason  in 
the  form  of  the  pelve,  and  possibly  in  the  mode  in 
which  tlie  presentation  occurs. 

Of  the  terrible  sciatica  of  alcohol  I  need  say  nothing 
here,  and  that  lead  or  arsenic  may  canse  sciatic  neural- 
gia of  neuritic  type  is  also  to  be  remembered. 

Strange  as  it  may  seem,  one  may  be  misled  for  a 
time  as  to  diagnosis  by  a  subacute  inflammation  of  the 
hip-joint,  with  aches  about  the  knee,  slight  wasting,  and 
stiffness.  As  between  this  and  the  sciatic  pain  which 
exists  chiefly  in  and  around  the  foramen  of  exit  and 
has  caused  nutritive  changes  in  the  gluteal  muscles,  one 
is  at  times  troubled  to  decide.  At  all  events,  I  have 
seen  surgeon  and  physician  err  one  way  or  another  as 
to  these  maladies. 

And  now  as  to  one  or  two  matters  connected  with 
sciatic  pain,  before  we  consider  the  treatment  of  sciatic 
neuritis  and  the  neuralgias  likely,  under  conditions 
adverse  to  recovery,  to  eventuate  in  the  more  serious 
malady.  I  shall  presume  upon  your  full  knowledge 
of  the  symptoms  of  sciatica.  The  gait,  the  wasting, 
the  pain-points,  and  the  hyperesthesia  or  anaesthesia  I 
may  pass  over  as  familiar.  But  look  now  at  the  case 
I  show  you  from  McCormick  ward.  When  this  man 
entered  here  he  had  violent  pain  at  the  sciatic  notch  on 
carrying  the  leg  forward.  A  case  near  by,  now  well, 
had  pain  down  the  leg  on  putting  the  leg  far  back,  and 
at  each  step  as  tlie  leg  on  which  he  stood  reached  its 
extreme  limit  of  backward  position.  The  forward  swing 
eased  him.  A  case  seen  last  year  fell  as  if  shot  when 
he  stood  on  the  lame  leg,  the  pain  darting  down  the 
limb  from  the  notch.  A  few  years  ago  I  saw  a  still 
worse  example  of  this  form  of  pain.     In  this  latter 


THE  TREATMENT  OF  SCIATICA.  159 

case,  after  long  treatment,  I  found  that  very  deep  pres- 
sure at  or  over  the  notch  caused  acute  pain.  Finally, 
we  cut  down  (I  think  it  was  Dr.  Morton  who  operated) 
and  found  a  small,  round,  hard,  fibrous  growth  just 
over  the  point  of  exit  of  the  nerve.  Its  removal 
brought  about  a  speedy  recovery.  Extreme  lift  of  the 
leg  iu  sciatica  nearly  always  gives  increase  of  pain, 
and  some  sciatica  patients  who  have  suffered  long  care- 
fully limit  the  length  of  their  step  so  as  not  to  make 
any  pull  on  the  nerve. 

Walking  exercise  usually  makes  the  pain  of  sciatic 
neuritis  worse.  The  cause  is,  perhaps,  not  so  simple  as 
it  may  seem  to  you.  Of  course,  it  is  natural  to  presume 
— is,  I  think,  generally  taken  for  granted — that  the 
rhythmic  tension  of  the  muscles  at  the  notch  squeezes  a 
swollen  nerve  as  we  walk  or  stand,  and  thus  increases 
the  suffering. 

I  have  taken  some  pains  to  see  how  far  this  may  be 
true.  The  result  of  a  brief  study  of  dissections  made 
for  me  by  Dr.  Addinell  Hewson,  that  I  might  investi- 
gate the  matter,  proved  of  interest,  especially  as  the 
anatomies  did  not  make  it  entirely  clear. 

The  great  sciatic  emerges  from  its  foramen  with  ample 
space  around  it.  Then  it  lies  in  an  irregular  triangular 
gutter  between  the  tuber  ischii  and  the  great  and  lesser 
trochanters.  This  space  is  over-large  and  narrows  or 
widens  as  inversion  or  eversion  of  the  foot  and  leg  turns 
the  head  of  the  bone  inward  or  outward.  Above,  or 
posteriorly,  this  deep  gutter  is  covered  by  the  gluteus 
maximus.  At  the  lower  edge  of  this  muscle  the  deep 
fascia  turns  under  it  and  then  is  reflected  downward,  so 
as  to  roof  over  the  lower  part  of  the  sciatic  gutter  with 
a  dense  covering,  which  is  attached  to  the  ischial  tuber- 


160 


NERVOUS  DISEASES. 


osity,  and  to  a  part  of  the  lesser  trochanter.  This 
fascia  thns  forms  a  strong  tentorium,  protecting  the 
nerve  more  or  less  from  external  violence.  The  pyri- 
form  muscle,  which  overlies  the  nerve,  is  so  situated 
that  it  crosses  where  the  nerve,  lying  rather  free  in  its 


Fig.  2. 


Drvided  hody 

Pyrifomi  s 
M21  ^cli 


Anomalous  high  division  ot  great  sciatic  nerve,  one  branch  passing  through 
pyriformis  muscle. 

notch,  could,  even  if  swollen,  with  difficulty  suffer 
from  the  action  of  this  muscle.  In  front  of  the  nerve 
lie  the  quadratus  and  gemelli  and  the  tendon  of  the 
obturator.  When  these  muscles  swell  in  such  contrac- 
tile effort  as  everts  the  foot  they  may  more  or  less  press 
upon  the  nerve,  but  the  consentaneous  action  of  the 


THE  TREATMENT  OF  SCIATICA.  \Q\ 

tightening  mass  of  the  gluteus  must  tend  to  enlarge 
the  cavity  in  front  of  it  and  make  tense  its  roof,  so  that 
unless  immense  swelling  of  the  nerve  be  present  or  a 
growth,  the  activity  of  these  muscles  could  scarcely 
cause  pinching  or  pressure  of  moment. 

Dr.  J.  M.  Taylor  called  my  attention  to  the  fact  that 
in  1600  sciatic  nerves  there  were  49  anomalies  of  a 
nature  to  cause  quite  surely  pain  in  a  swollen  nerve 
when  the  pyriformis  acts.  In  these  anomalies  the 
nerve  divides  so  that  one  part  goes  through  the  belly 
of  the  muscle — as  is  well  seen  in  Dr.  Taylor's  sketch. 
As  a  fact,  eversion  or  inversion  of  the  foot  rarely  gives 
rise  to  increase  of  sciatic  ache.  We  must  look  else- 
where for  explanations.  It  seems  to  me  probable  that 
the  forward  swing  of  the  leg  in  walking  may  be  felt 
because  at  its  full  limit  it  must  repeatedly  stretch  the 
nerve  a  little,  and  very  little  is  needed  to  hurt  an 
inflamed  nerve.  Thus,  going  up  stairs,  which  stretches 
the  nerve  far  more,  is  painful.  Also,  we  should  re- 
member that  the  thigh-muscles,  bound  down  by  tense 
fascia,  may  in  action  somewhat  compress  the  track  of 
the  nerve. 

Whether  any  of  the  exceptional  cases  of  violent 
anguish  referred  to  the  notch  on  standing  are  due  or 
not  to  the  anomalous  peculiarity  mentioned  I  cannot 
say. 

Very  rarely,  it  is  the  backward  motion  which  causes 
pain,  and  for  this  I  can  see  no  competent  explanation. 

I  sus])ect  that  very  often  the  pain  increased  or  repro- 
duced by  walkiug  is  due  to  more  mysterious  causes, 
which  are  of  central  origin  and  analogous  to  such  as  are 
present  in  facial  neuralgias  when  the  patient  chews  or 
swallows,  talks  or  laughs.     Then  there  seems  to  arise  a 

14* 


162  ^'EB  VO  US  DISEASES. 

sudden  reinforcement  of  capacity  to  feel  pain  on  the 
part  of  the  nerve-centres.  It  is  also  quite  sure  that 
certain  sciatic  cases  are  eased  by  exertion;  probably 
these  are  not  cases  of  neuritis. 

I  wish  to  say  a  few  words  as  to  the  time  of  the  ex- 
acerbations of  pain  in  sciatica.  I  have  studied  with  some 
care  the  hour  of  greatest  pain  in  neuralgias,  and  I  think 
I  may  be  secure  in  stating  that  for  fifth-nerve  neural- 
gias it  is  likely  to  be  before  noon,  and  for  sciatica  after 
4  P.M.  In  many  cases  of  the  latter  malady  it  is  between 
12  at  night  and  4  a.m.  ;  these  figures  are  the  result  of 
an  examination  of  something  like  a  hundred  neuralgias. 

Whilst  this  holds  good  for  our  own  climate,  it  may  be 
quite  untrue  elsewhere,  as  in  the  South  or  in  England. 
I  mention  this  because  abroad  the  remarkable  statistics 
of  my  clinics,  and  the  studies  of  Dr.  Morris  Lewis  and 
of  the  author  on  chorea  in  relation  to  seasons,  have  been 
doubted,  or  declared  not  to  have  been  confirmed  by 
European  observers.  It  would  be  odd  enough  if  they 
were,  as  almost  inevitably  the  relation  of  pain  or  other 
morbid  phenomenon  to  time  of  day  or  year  may  differ 
in  one  continent  from  another.  It  is  the  comparative 
results  which  become  interesting. 

As  regards  this  question  of  the  time  of  pain-occur- 
rence there  are  valuable  papers  by  myself  ^  and  by 
Captain  Catlin,^  U.  S.  A.,  which  exhibit,  as  concerns 
a  remarkable  case  of   traumatic  neuralgia,   a  curious 

1  Relation  of  Pains  to  Weather,  by  S.  Weir  Mitchell,  M.D.  American 
Journal  of  the  Medical  Sciences,  April,  1877. 

-  Relations  of  Pain  to  Weather,  Studied  during  Eleven  Years  of  a  Case 
of  Traumatic  Neuralgia,  by  Captain  R.  A.  Catlin,  U.  S.  A.,  with  Notes  by 
S.  Weir  Mitchell.  Transactions  of  the  College  of  Physicians,  Philadelphia, 
1883. 

Memoirs  of  the  National  Academy  of  Sciences,  1892.  Final  report  by 
Captain  Catlin, 


THE  TREATMENT  OF  SCIATICA.  163 

teDdency  to  the  increase  of  pain  at  set  periods  of  the 
day. 

Sciatic  pain  tends  to  be  worse  at  night.  The  treat- 
ment should^  so  to  speak,  follow  it  into  this  period; 
and  this  is  why  I  have  insisted  here  on  the  time- 
question  . 

And  now  let  us  pass  on  to  the  treatment.  If  you 
turn  to  the  text-books,  as  to  this  aud  other  well-studied 
diseases,  you  will  find  a  bewildering  list  of  drugs,  and 
mechanical  and  other  treatment  mentioned,  with  the 
constant  introduction  of  "  So-and-so  has  been  or  may 
be  used;'^  also,  ^^Gr  recommends  this,  K  that,  in  this 
disorder."  Dropping  all  this  puzzling  list  of  drugs, 
and  what  not,  I  shall  now  tell  you  what  I  usually  do 
here,  and  do  m  succession  in  these  cases,  as  improve- 
ment or  failure  makes  desirable.  In  private  practice 
you  cannot  always  do  at  once  as  you  wish  to  do,  or 
think  really  best.  Except  as  to  that  which  money 
brings — change  of  climate  and  the  like — so  far  as  mere 
immediate  treatment  is  concerned — the  poor,  in  a  hos- 
pital like  this,  have  sometimes  a  better  chance  than  the 
rich  or  highly  placed,  as  certain  illustrious  precedents 
have  proved. 

If  in  the  text-books  the  list  of  drugs  and  counter- 
irritants  were  followed  by  a  clear  statement  of  what  the 
author  advised  in  mild  or  in  grave  cases,  these  books 
would  acquire  a  definite  and  individualized  value.  One 
may  read  all  that  Gowers,  or  Gray,  or  Dana  says,  and, 
if  young  in  practice,  rise  without  the  least  distinct  idea 
as  to  just  how  these  able  men  treat  their  own  cases  of 
sciatica.  You  may  rest  assured  that  they  are  more 
definite  in  their  practice  than  might  be  inferred  from 
their  books.    The  treatises  on  mere  therapeutics  are  yet 


164  NEB  VO  US  DISEASES. 

worse.  In  one  is  a  list  of  forty  agents  which  may  be 
used  in  sciatica. 

Let  us  say  that  we  have  to  deal  with  a  mild  case,  a  first 
attack.  The  usual  careful  search  through  the  organs 
and  secretions  has  been  made.  Any  obvious  constitu- 
tional disorder  is  provided  for.  What  next  ?  As  to 
this,  all  are  at  one — rest  in  bed,  constant  and  prolonged, 
till  recovery  is  assured.  Few  things  are  as  valuable 
as  dry  cups,  if  you  use  them  thoroughly  and  early. 
Very  effective  is  a  double  or  even  a  triple  row  of  caps 
all  around  and  over  the  notch  and  down  the  leg,  along 
the  nerve-branches  to  the  ankle.  There  should  be  some 
three  dozen  cups  simultaneously  applied,  and  they 
should  remain  on  half  an  hour,  but  not  be  used  so  as 
to  blister.  This  measure  is  repeated  the  next  day; 
then  two  days  later,  and  this  alone  may  answer.  Or, 
if  for  any  reason  you  cannot  do  this,  put  on  mustard, 
at  least  three  inches  wide,  from  notch  to  ankle ;  or,  at 
least,  to  the  knee.  Add  a  little  molasses  to  the  mus- 
tard, and  you  may  then  leave  it  on  for  hours;  and  this, 
too,  may  answer.  Some  of  the  elder  doctors,  like  Pear- 
son, knew  the  fact  that  very  extensive  moderate  counter- 
irritation  is  often  better  than  limited  and  more  severe 
attacks  on  the  skin  by  irritants. 

If  these  means  fail,  what  is  to  be  done  next  ?  As 
to  this  I  hesitate  no  longer,  but  go  on  at  once  to  the 
means  I  now  employ  in  chronic  cases.  But,  at  the 
beginning,  and  perhaps  later,  until  you  can  perma- 
nently ease  the  ache,  it  is  needful  sometimes  to  use 
narcotics.  Cocaine  is  the  best,  in  from  one-fourtli  to 
one-half  grain  hypodermatic  injections.  How  rarely 
we  use  narcotics  here,  even  in  our  worst  cases  of  sciat- 
ica, the  resident  physicians  very  well  know.     If  you 


THE  TREATMENT  OF  SCIATICA.  165 

prefer  morphia,  give  one  dose  at  about  8  or  9  p.m.,  and 
get  rid  of  it  soon. 

Bat  suppose. the  disease  prove  intractable?  Let  us 
take  the  case  in  which  mild  irritants,  rest  in  bed,  and 
constitutional  means  have  failed;  or  that  of  the  old 
hospital  guest  who  has  carried  pain  with  him  from 
ward  to  ward  this  year  or  two. 

Consider  a  moment  the  attitude  and  ways  of  a  really 
severe  case  of  neuritis,  and  let  us  see  what  guides  these 
obviously  offer.  The  man  lies  in  bed  with  the  leg 
slightly  bent  at  the  knee  and  hip.  If  he  wishes  to 
turn,  he  keeps  the  limb  rigid — splints  it,  let  us  say,  by 
the  use  of  his  muscles,  aids  it  with  the  stay  of  support- 
ing hands.  In  the  exacerbations,  in  the  anguish  of 
the  night's  increase  of  pain,  a  toucjh,  even  slight  fric- 
tion of  the  bedclothes,  increases  the  distress.  It  was 
while  watching  such  cases  that  it  occurred  to  me  to  use  a 
sj^lint  to  keep  the  limb  quiet.  If  I  could  by  this  means 
forbid  the  use  of  muscles,  I  should  thus  far  secure  to 
the  nerve  physiological  rest,  which,  for  many  reasons, 
seemed  desirable.  If  free  motion  gave  pain,  all  motion 
might  be  relatively  hostile  to  recovery.  At  a  much 
later  date  I  was  struck  with  the  familiar  fact  that  all 
contacts  were  avoided  in  certain  cases  and  that  any 
sudden  touch,  even  that  of  the  bedclothes,  was  able  to 
increase  the  pain.  It  seemed  to  me,  as  I  considered  the 
matter,  that  such  unequal,  irregular  contacts  might  be 
hurtful,  and  that  by  a  bandage  I  could  secure  the  sur- 
faces from  these,  and  thus  still  further  insure  to  the 
nerve  functional  repose.  Finally,  it  was  possible  that 
the  bandage  might,  by  gentle,  firm,  general  pressure, 
lessen  the  amount  of  blood  circulating  in  the  leg,  and 
thus  relieve,  just  as  one  eases  an  aching  finger  by  firmly 


166  ^ER  VO  US  DISEASES. 

grasping  it.  Mj  success  seems  to  be  a  justification  of 
the  reasoning;  but  that  is  of  little  moment.  There  is 
much  good  treatment  which  we  cannot  explain. 

There  are  many  ways  of  doing  these  two  things. 
But  whether  you  suspend  the  leg  in  a  splint,  or  use 
wire  or  moulded  splints,  the  splint  must  check  motion 
at  the  hip  and  knee.  This  is  the  essential  matter.  The 
bandage  must  be  of  thin,  pure  flannel,  and  reach  from 
foot  to  groin.  I  have  used  rubber  or  elastic  stockings, 
and  also  combined  use  of  the  splint  with  pressure  by 
plaster  or  other  splint  dressings.  Practically  here  we 
use  for  all  true  sciaticas  a  firm  flannel  bandage  from 
foot  to  groin  and  reapply  it  twice  a  day.  The  leg  is 
slightly  bent  at  the  knee  and  kept  nearly  straight  at 
the  thigh,  and  in  this  position  secured  to  a  light  side- 
splint  from  axilla  to  ankle  by  a  few  turns  of  a  bandage. 
Care  is,  of  course,  taken  to  prevent  pressure  on  the 
heel.  After  a  few  days  the  joint-angles  are  slightly 
changed  at  each  dressing.  Still  later,  as  the  pain  fades, 
the  joints  are  mildly  and  passively  exercised  whenever 
the  bandages  are  renewed.  Usually  three  weeks  must 
pass  before  we  can  begin  to  abandon  treatment;  a  much 
longer  time  may  be  needed  for  old  cases.  Finally,  we 
take  off  the  splint  in  the  day,  but  leave  the  bandage  on. 
At  night  we  replace  the  splint.  Later  we  give  up  the 
splint,  and,  with  the  presence  or  absence  of  pain  as  our 
sole  guide,  in  like  manner  we  omit  the  bandage,  now 
in  the  day,  and  finally  at  night,  but  not  at  all  until 
the  patient  has  begun  to  move  about,  and  perhaps  not 
then. 

Meanwhile  with  cod-liver  oil,  iron  at  need,  good  diet, 
care  as  to  the  bowels,  never  allowing  a  costive  passage, 
forbidding  effort  at  stool  (preventing  it  by  hot  enemas) 


THE  TREATMENT  OF  SCIATICA.  167 

— by  these  means,  I  repeat,  we  carry  the  man  througli. 
When  the  pain  has  qnite  gone  we  use  mild  massage 
once  a  day  before  replacing  the  l)andages.  The  process 
must  be  careful,  with  avoidance  of  roughness. 

There  may  be  left,  near  the  close  of  this  treatment, 
one  or  more  points  of  persistent  pain,  not  often  severe. 
These  are  best  treated  by  counter-irritants,  the  best  being 
the  light  touch  of  a  wliite-hot  Paquelin  button,  or  a 
small  blister. 

The  getting  up  of  a  severe  sciatic  case  is  not  unim- 
portant. Motion,  the  full  use  of  the  leg  and  buttock 
muscles,  and  the  pressure  of  the  hard  edge  of  a  chair, 
or  close  stool,  are  likely  to  bring  back  pain.  Hence, 
we  do  not  allow  a  man  to  sit  at  all  the  first  week  that 
he  is  up.  He  must  at  first  stand,  and  then  walk,  but 
always,  whether  lie  walk  or  stand,  it  must  be  with  the 
aid  of  crutches.  He  may  be  upright,  or  lying  on  a 
bed,  but  not  seated.  Electricity  is  rarely  needed,  even 
if  there  has  been  much  wasting.  With  exercise  and 
massage,  or  without  the  latter,  the  muscles  usually  get 
strong. 

I  have  said  no  word  of  the  use  of  continuous  cold  so 
much  employed  here  before  the  bandage  and  splint 
combined  were  found  to  triumph  readily  over  most 
cases.  It  is  still  occasionally  employed.  The  method 
I  have  elsewhere  detailed  at  length  in  the  Interna- 
tional Lecture  Series.  It  gives  us  a  resource  of  great 
value  if  the  less  troublesome  plan  should  ha2:)pen  to 
fail ;  and  failure  is  rare  unless  the  neuritis  has  gone  up 
the  nerve  into  the  sacral  plexus,  or  unless  the  pain  is 
really  spinal  in  its  origin.  My  former  published  cases 
involved  the  combined  use  of  ice  and  splint-rest.  Those 
I  have  shown  you  of  late  were  treated  chiefly  with  the 


168  NER  VO  US  DISEASES. 

tight  bandage  and  long  splint,  to  which  you  may  add 
ice-bags  at  need.  The  rapid  gain  to  be  had  in  an  old 
case  of  sciatic  pain  out  of  these  means — the  flannel 
bandage,  splint-rest,  and  ice — must  be  seen  to  be  fitly 
appreciated,  and  I  may  add  that  in  mild  cases  the  tight 
bandage  used  alone  is  often  of  value.  I  do  not  claim 
for  these  simple  means  any  such  certainty  as  seems 
usually  to  be  demanded  from  novel  methods.  I  find, 
however,  that  I  rarely  fail,  and  that  my  colleagues,  like 
myself,  are  using  these  means.  It  is  with  me  an  old 
treatment,  for  in  1872,  in  my  book  on  Xerve  Injuries, 
p.  72,  I  used  these  words: 

"When  the  disease  is  really  subacute  and  the  nerve 
tender  on  pressure  for  some  considerable  part  of  its  length, 
I  insist  upon  the  most  absolute  rest.  If  it  be  the  leg  which 
is  attacked,  the  patient  must  go  to  bed  and  consent  to  wear 
a  carved  splint  for  several  weeks.  If  it  be  the  arm,  a 
sphnt  answers  to  put  it  in  a  state  of  repose,  and  without 
this  it  is  vain  to  employ  other  means. 

"  Cold  should  be  used  over  the  nerve-track  by  means  of 
Chapman's  spine-bag,  or,  better,  by  such  as  are  now  made 
by  the  Davidson  Rubber  Company,  which  are  thinner  than 
those  of  English  make.  The  caoutchouc  bag  should  be 
inclosed  in  a  case  of  thin  flannel,  and  may  then  be  kept  in 
situ  by  a  splint  and  a  bandage,  if  a  splint  be  worn.  In 
most  instances  I  have  used  them  over  nearly  the  whole 
length  of  the  main  nerve,  and  have  usually  contented  my- 
self with  their  employment  in  the  daytime.  In  some  cases, 
however,  I  have  had  them  renewed  twice  in  the  night,  and 
this  plan  I  believe  to  be  the  better  of  the  two.  The  only 
difficulty  lies  in  the  first  pain  from  cold,  and  is  easily  over- 
come. The  relief  afforded  is  often  remarkable,  and  the 
loss  of  the  nerve  in  size,  hardness,  and  tenderness  most 
gratifying." 


THE  TEE  A  TMENT  OF  SCI  A  TIC  A .  1^9 

The  following  briefly  stated  cases,  for  which  I  am 
indebted  to  Dr.  J.  M.  Taylor,  sufficiently  illustrate  my 
practice.      Many  more  might  have  been  added. 

Case  LI. — J.  M.,  aged  thirty-six  years,  born  in  Ireland,  a 
carpenter,  as  a  boy  had  some  kind  of  bone-disease  involving 
the  left  tibia,  with  a  purulent  discharge.  Eight  years  ago  he 
fell  forty  feet,  hurting  his  left  hip.  He  drinks  rather  freely 
of  whiskey,  smokes  excessively,  and  denies  venereal  disease. 
There  was  no  neuralgia  in  the  leg  until  three  years  since, 
when  it  began  with  a  dull  pain  in  the  region  of  the  sciatic 
notch,  and  passed  along  the  outer  aspect  of  the  thigh  to 
the  knee.  The  pain  is  now  confined  to  the  course  of  the 
left  sciatic  nerve ;  it  is  constant  and  worse  at  night ;  it  is 
increased  in  the  act  of  sitting  down,  and  on  rising  from 
this  position  there  is  much  less  pain. 

Examination  of  the  various  organs  proved  negative.  A 
scar  was  found  on  the  left  leg,  at  the  junction  of  the  upper 
and  middle  thirds  of  the  tibia;  there  is  another  a  little 
posteriorly  to  this,  and  a  third  lower  down ;  these  resulted 
from  old  sores,  which  finally  healed  ten  years  ago.  The 
pupils  react  to  accommodation  and  light ;  knee-jerks  and 
elbow-jerks,  and  plantar  reflexes,  etc.,  are  normal. 

The  measurements  of  the  thigh,  nine  inches  above  patelhi, 
were:  R.,  21  in.;  L.,  18  in. 

The  thigh,  six  inches  above  the  patella,  measured  :  R., 
18i  in.;  L.,  16  im     The  calf  :  R.,  13  in. ;  L.,  13*  in. 

He  responded  normally  everywhere  as  to  touch,  tested 
with  the  sesthesiometer ;  localization  was  good ;  urine 
analysis  was  negative. 

The  patient  was  admitted  to  the  hospital  February  18, 
1892,  in  a  state  of  extreme  suffering. 

The  treatment  ordered  was  absolute  rest,  good  diet,  milk 
between  meals,  iron  and  quinine,  flannel  bandage,  and 
massage.     He  managed,  with  phenacetin,  to  do  without 

15 


1 70  NER  VO  US  DISEASES. 

opiates,  and  on  the  fourth  (Lav  of  treatment  he  ceased  to 
feel  acute  pain. 

On  March  od  no  pain  was  complained  of  and  the  splint 
was  removed  ;  the  limb  was  kept  straight. 

On  ]March  14th  the  weight  of  the  body  cautiously  put 
upon  the  left  leg  was  followed  by  no  pain. 

On  March  oOth  the  man  was  well  able  to  mov^e  freely 
without  pain  ;  no  cautery  or  treatment  other  than  the  ban- 
dage and  splint  was  needed,  massage  having  been  aban- 
doned early.  He  had  a  slight  relapse  on  the  16th,  owing 
to  his  having  risen,  incautiously  and  without  a  crutch,  to 
assist  a  patient  Avho  had  fallen. 

This  was  a  clear  case  of  sciatic  neuritis,  with  much 
w^asting.  Seen  after  ruauy  months  he  was  still  free 
from  pain. 

Case  LII.  Double  Sciatica. — K.  P.,  a  porter,  aged  fifty- 
seven  years,  a  German  ;  married,  has  seven  children  ;  was 
never  ill  until  December,  1891,  when  he  had  what  he  de- 
scribes as  a  bilious  attack,  which  kept  him  abed  three  weeks. 
He  broke  two  ribs  three  years  ago.  There  was  no  evidence 
of  syphilis.  In  October,  1891,  he  had  a  rheumatic  swelling 
of  the  right  ankle.  A  little  later  the  pain  extended  up 
the  line  of  the  posterior  tibial  nerve,  and  generally  along 
that  of  the  main  trunk.  It  was  worse  upon  exertion,  and 
was  eased  by  recumbency.  Nevertheless,  he  went  on  with 
his  rather  heavy  work  until,  after  exposure  to  wet,  the 
pain  became  far  worse  and  the  knee  somewhat  stift.  At 
times  he  could  no  longer  walk,  and  had  also  aches  in  the 
back  and  in  the  left  leg. 

In  August  he  had  severe  cramps  in  both  legs  and 
limped  increasingly.  Still,  under  dire  pressure  of  need, 
he  continued  to  work.  Late  in  August  he  had  solar  ex- 
haustion, and  at  the  Pennsylvania  Hospital  was  treated 
by  ice-rubbing.     This,  he   thinks,  chilled   him   severely. 


THE  TREATMENT  OF  SCIATICA.  171 

The  next  day  intense  pain  arose  in  the  left  leg,  grew 
worse,  and  he  became  able  to  work  only  intermittently. 
The  pain  now  (October  14th),  on  admission,  is  very  severe 
over  the  right  sciatic  and  in  the  thigh  and  the  calf  of  the 
right  leg.  There  is,  also,  pain  on  pressure,  but  none  in 
the  sciatic  notch  or  in  the  popliteal  space.  In  the  left  leg 
pain  is  very  marked  on  pressure  along  the  entire  course  of 
the  sciatic.     There  is  no  pain  in  the  back. 

Measurements.  Thigh:  R,,  18  in.;  L.,  16  in.  Calf: 
R.,  13  J  in. ;  L.,  13  in.  Dynamometer  :  R.  hand,  125  ; 
L.  hand,  125. 

The  knee-jerks  on  both  sides  are  normal,  and  there  is  no 
clonus  ;  the  elbow-jerks  on  both  sides  are  normal,  and  there 
is  no  impairment  of  muscle-jerks  ;  sensation  is  everywhere 
good ;  the  heart,  lungs,  kidneys,  etc.,  are  normal.  To 
stand  long  occasioned  pain  in  both  legs,  es2:)ecially  in  the 
thighs ;  walking  is  difficult  and  painful.  In  November, 
1892,  on  taking  charge,  I  found  this  man  in  bed,  having 
had  elsewhere  many  forms  of  treatment,  all  unsuccessful. 
He  was  ordered  full  diet,  rest  in  bed,  with  flannel  ban- 
dages to  both  legs.  On  the  third  day  he  became  nearly 
free  from  pain.  Thereafter  the  usual  changes  as  to  splint 
and  bandage  were  made.    It  seems  needless  to  repeat  them. 

On  December  2d  he  was  allowed  to  walk  a  little  on 
crutches,  but  not  to  sit  down.  Two  pain-points  in  the 
upper  thigh  were  lightly  cauterized.  He  was  discharged 
December  12,  1892,  apparently  well. 

This  appears  to  have  been  a  case  of  true  double  sci- 
atica, probably  rheumatic.  I  learn  that  he  is  now  (April 
1st)  well  and  at  work.  The  immediate  effects  of  the 
splint  and  bandage  were  very  gratifying. 

Case  LIH. — G.  C,  aged  sixty-five  years,  is  a  machinist ; 
he  drinks  and  smokes  moderately ;  is  very  rarely  ill. 
During  the  war  he  had  ''  camp  fever."  He  denies  venereal 


172  NER  VO  US  DISEASES. 

history.  He  is  married ;  has  had  nine  children,  five  are 
living  and  four  dead.  Suddenly,  six  weeks  ago,  pain  began 
in  the  left  hip  and  leg ;  the  left  foot  feels  asleep  quite 
constantly ;  the  pain  grows  worse  at  night,  on  change  of 
weather,  on  rising  from  a  chair,  and  while  walking  or 
going  up  steps. 

The  man  is  pale  and  thin  and  has  the  gait  of  one  in 
much  23ain  ;  the  left  leg  is  held  stifily.  The  left  knee-jerk 
is  slightly  in  excess  of  the  right.  Pressure  over  the  left 
sciatic  notch  causes  pain,  and  also  along  the  course  of  the 
nerve.  He  was  admitted  to  the  hospital  March  5,  1892, 
and  was  ordered  absolute  rest  in  bed,  flannel  bandages, 
straight  splint,  extra  diet,  milk,  iron,  and  cod-liver  oil. 
On  ]March  10th  the  report  says  that  the  pain  disappears 
in  the  daytime,  but  at  night  is  sufiiciently  severe  to 
keep  him  awake.  On  March  13th  all  pain  has  disap- 
peared, except  a  soreness  over  the  external  condyle  of  the 
femur  and  external  malleolus  where  it  is  in  contact  with 
the  splint.  He  now  sleeps  well.  On  March  18th  all  pain 
is  lost,  even  upon  deep  pressure.  On  March  21st  the 
splint  is  removed  in  the  daytime,  but  the  limb  is  to  be 
kept  in  extension  and  quiet.  The  splint  was  applied  at 
night  until  the  26th  inst.  The  bandage  was  constantly 
used,  and  he  walked  with  crutches.  He  has  had  slight 
relapses,  necessitating  the  use  of  the  splint  for  a  day  or 
two.  On  March  28,  1893,  he  was  discharged  well — a 
rapid  recovery. 

Case  LIV. — P.  G.,  aged  fifty  years,  had  the  interest- 
ing combination  of  sciatica  and  erythromelalgia.  The 
family  history  was  negative.  He  was  a  married  man 
with  six  children,  all  well.  In  the  army  he  had  a  severe 
attack  of  measles  followed  by  dysentery,  and  later  typhoid 
fever  ;  he  was  ill  five  months.  After  the  war  he  had 
malarial  fever.  Seven  years  after  the  first  attack  of  dys- 
entery he  had  a  second  attack  which  lasted  five  vears, 


THE  TREATMENT  OF  SCIATICA.  173 

during  which  time  he  passed  much  blood   and  mucus  ; 
most  of  this  time  he  continued  at  work  and  often  voided 
twelve  stools  daily.     During  the  last  five  years  the  man 
had  been  pretty  well.     He  had  never  had  any  special  in- 
jury, but  has  not  been  very  strong  since  the  last  attack  of 
dysentery.      He  worked  as  a  lumberman  for  five  years, 
being  out  in  all  weathers.     In  January,  1889,  he  began 
to  work  in  the  coal-mines.      Since  his  army-life  he  has 
had  some  fleeting  rheumatic  pains  now  and  again.     The 
present  trouble  began  January,  1889,  while  at  work  in  a 
mine,   with   severe  shooting-pain   in   the    right   arm    and 
shoulder,  noticed  while  at  rest,  but  disappearing  on  mo- 
tion.    This  lasted  three  weeks.     He  sleeps  habitually  on 
the  right  side  and  had  need  to  keep  the  arm  flexed.     One 
month  after  this,  pain  began  in  the  left  hip,  shooting  dow^n 
the  course  of  the  sciatic  to  the  calf  and  ankle,  and  being 
of  greatest  intensity  from  the  knee  to  the  ankle.     He  was 
then  confined  to  bed  four  weeks ;  on  the  slightest  move- 
ment the   pain  was  much  increased  ;  this  gradually  les- 
sened, but  the  man  was  unable  to  work  for  five  months. 
He  describes  the  pain,  when  it  began,  as  a  burning  and 
crawling  sensation  in  the  right  leg,  as  if  the  flesh  was  on 
fire ;  this  continued  in  both  feet  in  very  severe  degree ;  he 
could  place  his  right  foot  on  the  floor,  but  not  the  left  one, 
on  account  of  excessive  pain.    After  two  months'  treatment 
he  had  improved,  but  was  unable  to  work  for  five  months. 
He  was  pretty  well  until  January,  1892,  at  which  time  pain 
of  similar  kind,  but  more  severe,  attacked  the  back  and 
left  hip,  seeming  to  warp  the  body  to  the  left  side.     Much 
pain  was  caused  by  any  attempt  to  straighten  the  body, 
shooting  down  the  left  leg  into  the  foot  and  toes.     He  was 
again  confined  to  bed  for  four  months.     He  was  in  the 
Jefferson   Hospital   in   May,  1892,   for   five   Aveeks.     He 
finally  was  well  enough  to  go  home,  but  could  not  walk, 
and  on  arriving  the  pain  grew  worse.     Since  May,  while 

15* 


174  NEB  VO  US  DISEASES. 

standing  with  the  left  leg  pendant,  the  blood  seemed  to 
accnmiilate  in  the  foot  and  leg  up  to  the  knee  and  cause 
intense  pain. 

October  14,  1892.  The  left  leg  is  noticeably  shrunken 
and  flabby;  there  is  considerable  pain  on  pressure  over 
the  sciatic  notch,  with  soreness  over  the  calf-muscles,  but 
none  in  the  popliteal  space ;  there  is  no  shortening  of  the 
limb.     The  foot  is  red  and  hot  when  hanging  down. 

Measurements.  Thigh:  R.,  17  in.;  L.,  15  in.  Calf: 
K,  m  in. ;  L.,  11  in. 

There  is  slight  clonus  in  the  left  leg,  but  none  in  the 
right ;  the  knee-jerks  on  both  sides  are  normal ;  the 
plantar  and  skin  reflexes  are  normal  ;  there  is  slight 
hyperassthesia  in  the  left  leg  below  the  knee ;  the  heart, 
lungs,  etc.,  are  normal ;  the  bowels  are  inclined  to  be  loose 
and  irregular  ;  the  appetite  is  fair  ;  the  digestion  poor. 

This  man,  while  in  the  standing  position,  declares  him- 
self unable  to  allow  his  heel  to  touch  the  ground,  asserting 
that  it  would  pain  so  increasingly  and  furiously  as  to 
"drive  him  wild."  There  is  also  pain  on  pressure  over 
the  entire  sole  of  the  foot ;  pressure  caused  an  intense 
flushing  of  the  surface. 

The  treatment  ordered  was  absolute  rest,  flannel  ban- 
dages, the  straight  splint ;  massage,  except  to  the  left  leg  ; 
cod-liver  oil,  malt,  extra  food,  iron,  quinine,  and  strychnine. 

On  October  26th  the  pain  was  so  intense  that  ice  was 
applied.  On  December  2d,  the  vaso-motor  difficulty  not 
lessening  satisfactorily,  the  left  leg  and  foot  were  elevated. 
Internally,  sodium  phosj)hate  was  ordered,  forty  grains  in 
hot  water,  an  hour  before  meals,  to  relieve  the  constant 
catarrhal  condition  of  the  stomach. 

On  December  19th  the  man  was  very  much  improved  in 
respect  to  the  sciatic  pain  ;  he  gained  in  weight  and  vigor, 
and  he  was  allowed  to  go  home  on  the  20th,  as  he  declined 
to  remain  longer.     He  still  wore  the  flannel  bandage  and 


THE  TREA  TMENT  OF  SCI  A  TIC  A .  1 7  5 

used  crutches.     The  flushing  of  the  foot  was  not  better ; 
the  hypersesthesia  of  the  member  was  little  altered. 

As  usual  in  my  sad  experience  of  erythromelalgia, 
nothing  did  much  good  for  the  foot,  although  heat, 
cold,  electricity,  and  massage  were  used  with  care,  and 
I  give  the  case  as  it  left  us,  because  of  the  great  gain 
in  the  sciatic  pain,  which,  if  not  well,  was  vastly 
bettered  by  local  rest  and  bandage.  The  long  elevation 
of  the  leg  and  foot  seemed  to  make  the  nerve-tracks 
more  tender,  a  result  which  I  have  seen  before  and 
since,  nor  did  it  help  the  vaso-motor  complications.  I 
presume  this  man  to  have  a  quite  distinct  case  of  ery- 
thromelalgia,  with  sciatic  and  terminal  neuritis. 

You  may  with  reason  ask  what  I  do  if  the  treatment 
by  the  splint-rest  and  bandage,  or  by  splint-rest  and 
ice,  fail.  At  first,  to  clear  my  experimental  therapeu- 
tics from  needless  doubt,  I  used  these  means  only  in 
cases  which  I  was  sure  were  sciatic  neuritis,  and  this 
alone.  I  have  elsewhere  recorded  the  results.^  Of 
late,  and  since  I  felt  secure  as  to  my  process.  I  and 
others  have  used  these  means  in  cases  of  more  dubious 
nature — in  double  leg-pain,  in  those  who  had  certainly 
troubles  in  the  lower  cord.  In  such  examples  of  sciatic 
pain  of  central  origin  there  have  been  many  failures 
to  record — many  cases  in  which  splint-rest  did  no  good, 
or  little.  In  the  true  sciatic  cases  which  finally  defy 
all  medical  means  there  remains  for  consideration 
nerve-stretching.  I  have  seen  it  fail  when  my  own 
milder  means  succeeded.  I  believe  that  wdien  surgical 
nerve-stretching  is  employed  we  should  at  once  follow 
up  its  use  by  that  of  the  roller  and  splint-rest.     Some 

1  International  Lecture  Series. 


1 76  NER  VO  US  DISEASES. 

of  the  relapses  which  follow  its  successful  use  have,  I 
am  sure,  been  due  to  neglect  of  the  precautions  with 
which  in  very  case  of  neuritis  I  desire  to  surround  my 
patient.  lu  conclusion,  I  desire  to  add  that  I  do  not 
look  upon  splint-rest  and  the  bandage  as  certain  to  cure 
all  sciaticas,  but  as  sure  to  relieve  or  cure  most  cases, 
and  as  valuable  adjuncts  to  whatever  other  means  be- 
comes desirable. 


CHAPTEK    X. 

ERYTHROMELALGIA:  RED  NEURALGIA  OF  THE  EX- 
TREMITIES; VASO-MOTOR  PARALYSIS  OF  THE  EX- 
TREMITIES;  TERMINAL   NEURITIS. 

I  THINK  myself  fortunate  in  being  able  to  show  you 
this  morning  the  two  cases  now  before  us.  One  is  a 
typical  example  of  vasal  spasm  in  the  arterioles  of  the 
fingers,  and  is  known  as  Raynaud's  disease.  The  other 
is  tlie  remarkable  malady  which  I  first  described  in 
1872,  and  to  which  in  1878,  at  Professor  Ashhurst's 
suggestion,  I  gave  the  name  of  erythromelalgia  (redness, 
extremity,  pain);  ^^  red  neuralgia^'  some  like  to  call  it. 
It  is  inconceivable  that  these  two  disorders  should  ever 
have  been  confused,  and  yet  at  least  one  able  observer 
speaks  of  erythromelalgia,  dead  fingers,  local  asphyxia, 
local  syncope,  symmetrical  gangrene,  as  all.  being  simply 
different  types  of  Raynaud's  disease.  I  hardly  imagine 
anything  clinically  more  strange  than  to  consider  the 
cases  before  us  as  one.  Examples  of  Raynaud's  malady 
are  not  rare;  cases  of  erythromelalgia  are  very  uncom- 
mon. 

Here  before  you  are  two  peo})le.  One  is  a  pale,  ner- 
vous, excitable  woman,  whose  condensed  history  my 
clinical  aid  will  presently  read.  We  shall  somewhat 
abbreviate,  for  the  whole  matter  has  become  familiar, 
and,  except  as  to  the  mechanism  of  causation^  concern- 
ing the  clinical  features,  we  know  all  that  we  are  likely 

1  Medical  Record,  N.  Y.,  July,  1885. 


178  NER  VO  US  DISEASES. 

soon  to  know.   I  show  the  case  now  only  as  a  contrasted 
clinical  picture. 

Case  LV. — C.  L.,  single,  aged  thirty  years,  a  dress- 
maker, is  an  intelligent  woman.  She  has  had  no  grave 
illness,  but  after  a  long  strain  and  much  work  she  began 
to  have  the  well-known  corpse-fingers.  These  attacks  be- 
came severe  and  more  lasting,  and  by  and  by  passed  at 
times  into  the  condition  of  local  asphyxia,  the  fingers  be- 
coming livid  in  tint.  Later,  she  had  slight  gangrenous  loss 
of  all  the  finger-tips.  You  see  the  scars  on  the  finger-tips, 
now  white  and  cold.  This  state  may  come  and  go,  or  may 
end  in  the  livid  condition,  when  the  returning  blood  stays 
in  the  part  and  becomes  black. 

Observe  now  that  when  I  prick  the  livid  finger  the  blood 
flows  out  black,  and  does  not  redden  by  exposure.  It  is 
clear  that  it  is  locally  charged  with  excess  of  carbon 
dioxide,  but  has  no  other  peculiarities.  Many  of  Ray- 
naud's cases  suffered  much  pain.  This  woman,  like  others 
I  have  seen,  has  had  but  little. 

Case  LVI. — Turn  now  to  this  man  in  the  rolling-chair. 
Thin,  ruddy,  anxious-looking,  he  is  in  no  wise  hysterical, 
and  is  both  patient  and  intelligent.  His  face  bears  the 
signal-lines  of  pain.  Look  at  his  foot,  as  it  lies  on  the  ex- 
tended leaf  of  the  chair.  There  is  nothing  notable  about  it 
except  the  scars  of  an  old  injury.  It  is  like  the  other  foot 
— neither  red  nor  pale.  He  says  it  aches  continuously — a 
dull,  deep-burning  ache.  Also,  as  you  see,  it  is  tender  to 
deep  pressure  and  less  so  to  lighter  pressure,  except  as  to 
the  outside  and  as  to  the  heel  and  fourth  and  fifth  toes.  I 
ask  him  to  rise.  He  does  this  aided.  He  positively  will 
not  stand  on  the  foot.  He  leans  now  on  a  chair.  Almost 
at  once  three  of  the  toes  become  of  a  bright,  rosy  tint ;  then, 
beginning  in  island-like  spaces,  a  deeper  tint  covers  a 
large  part  of  the  foot.  The  arteries  throb.  The  veins 
stand  out  in  strong  relief.     In  a  few  minutes  the  vascular 


EBYTHROMELALGIA.  179 

tumult  lessens.  The  arteries  cease  to  throb.  The  redness 
becomes  dusky  or  in  places  purplish — not  livid,  as  in  the 
woman's  case.  At  once  the  dependency  of  the  foot  brings 
increase  of  pain,  and  this  gets  worse  until  he  will  stand  no 
longer  or  falls  fainting. 

In  like  degree  the  hypersesthesia,  both  of  depth  and  sur- 
face, is  augmented.  Finally,  the  touch  of  a  feather  gives 
pain,  and  deeper  pressure  sends  darts  of  pain  up  the  track 
of  the  posterior  tibial  nerve.  At  last  the  pain  is  unendur- 
able and  I  must  let  him  put  the  foot  up  again  on  a  chair. 

It  is  interesting  to  observe  how  unstable  everywhere  is 
his  surface-circulation  ;  how  flushes  come  and  go  over  the 
legs  and  trunk,  and  how  little  the  other  foot  changes  color. 

Surely,  no  two  more  entirely  separate  groups  of 
symptoms  could  be  found  :  this  cold,  white  band,  with 
its  pale  fingers,  free  from  pain  of  any  moment  and 
more  or  less  anaesthetic,  and  now  presently  livid ;  this 
hot,  deep-red  foot,  so  painful  that  its  torment  brings 
out  the  sweat  ou  the  sufferer's  brow. 

Before  dismissing  these  cases,  I  desire  to  say  a  few 
words  as  to  the  contrasts  they  offer. 

Lannois,  whose  book  I  mentioned,  thus  characterizes 
local  asphyxia,  or  symmetrical  gangrene,  and  erythro- 
melalgia.     I  have  somewhat  altered  his  definitions: 

Local  asphyxia  (Raynaud).  Erythromelalgia  (Weir  Mitchell). 

Sex :  Four-fifths  females.  In    twenty-seven    cases    two   were 

women. 

Begins  with  ischsemia.  Little  or  no  difference  of  color  is  seen 

until  the  foot  hangs  down  in  up- 
right posture,  when  it  becomes 
rose-red. 

The  affected  parts  become  bloodless       The  arteries  throb,  and  the  color  be- 
and  white.    In  certain  cases  there  comes  dusky-red  or  violaceous  in 

is  the  deep,  dusky  congestion  of  a  tint, 

cyanosed   part,  with   or   without 
gangrene. 


1 80  NER  VO  US  DISEASES. 

Local  asphy.da  (Raynaud).  Erythromelalgia  (Weir  Mitchell). 

Pain  may  be  absent  or  acute,  and  Pain  usually  present;  worse  when 
comes  and  goes ;  has  no  relation  to  the  part  hangs  down  or  is  pressed 

position.     May  precede  local  as-  upon.    In  bad  cases,  more  or  less 

phyxia.  at  all  times. 

Unaffected  by  seasons.  In  many  cases       Worse  in   summer  and  from  heat, 
all  the  symptoms  can  be  brought  Eased  by  cold, 

on  by  cold. 

Anaesthesia  to  touch.  Sensation  of  all  kinds  preserved. 

Analgesia.  Hyperalgesia, 

Temperature  much  lowered  and  un-       Temperature  greatly  above  normal 
altered  by  posture.  Dependency  causes  in  some  cases 

increase  of  heat ;  in  others  lower- 
ing of  temperature. 

Gangrene  local  and  limited  ;  likely       No  gangrene ;  asymmetrical, 
to  be  symmetrical. 

Erythromelalgia,  then,  is  a  chronic  disease  in  which 
a  part  or  parts — usually  one  or  more  extremities — suffer 
with  pain,  flushing,  and  local  fever,  made  far  w^orse  if 
the  parts  hang  down.  There  are  mild  cases  which  do 
not  progress,  and  which  may  come  and  go.  There  are 
others  which  exhibit  all  the  symptoms  to  such  a  degree 
as  to  make  the  disease  one  of  terrible  torment. 

In  1878,  when  my  second  paper  was  published,  I  pre- 
dicted that  the  malady  would  soon  be  shown  to  be  more 
comiDon  than  it  appeared  then  to  be — and  this  has 
proved  to  be  the  case.  Lannois's  treatise^  gives  many 
cases,  and  of  late  the  German  observers  have  delineated 
it  with  their  usual  care,  and  especially  Gerhardt.  At 
the  time  I  wrote  I  should,  if  driven  to  be  positive  in 
statement,  have  inclined  tow^ard  considering  this  malady 
as  due  to  some  form  of  spinal  disorder.  And  this  may 
yet  prove  more  or  less  true  of  some  of  the  cases,  or  of 
some  stage  of  the  cases.  But  at  present  the  reason- 
able explanations  incline  rather  toward  some  form  of 

1  Erythromelalgia,  1880,  p.  71. 


ER  YTHR.OMELALGIA.  1  gl 

that  new  clinical  perplexity,  peripheral  neuritis.  Light 
is  cast  on  the  matter  by  the  later  history  I  have  just 
obtained  of  the  case  of  Mr.  K.,  whom  I  saw  in  1876, 
and  whose  story  it  seems  worth  while  to  give  here  at 
length,  before  returning  to  the  discussion  of  causes. 
Here  is  a  brief  resume  from  my  paper  of  1878: 

Case  LVII. — G.  K.,  single,  clerk,  lost  his  right  arm  in 
war,  1862.  Army-life  was  too  exacting  for  his  strength, 
and  in  1864  an  attack  of  typhoid  left  him  with  impaired 
vision — relieved  in  1872  by  glasses.  Between  these  latter 
dates  the  foot-trouble  began,  with  burning  pain  and  red- 
ness, made  much  worse  by  exercise.  He  persisted  in 
walking  until  he  caused  blisters,  and  these  were  the  only 
nutrition-changes  I  have  ever  seen  in  this  disease.  In 
1875,  with  some  evidences  of  paresis  in  leg  and  arm,  the 
remaining  hand  became  red,  tender,  and  painful.  The 
case  was  typical.  In  July,  1877,  after  extremities  of 
anguish,  Mr.  K.  went  to  Elmira,  where  Dr.  Morris  Lewis 
saw  him  for  me  and  made  notes.  There  was  little  change 
as  to  the  disease ;  but  he  had  become  silent  and  morose, 
and  was  unable  to  be  out  of  bed.  From  November  to 
July  of  1877  he  had  nine  attacks  of  convulsions,  or  rather 
of  general  rigidity.  He  sj)oke  slowly  and  in  whispers. 
Clearly  he  had  become  more  or  less  hysterical. 

There  was  slight  oedema  from  the  waist  down.  Pressure 
on  the  spine  caused  pain,  and  the  extremities  were  very 
tender  everywhere.  The  finger-ends  were  bluish  and  cold. 
The  last  two  phalanges  were  smooth,  red,  and  shiny,  re- 
minding one  of  certain  cases  of  traumatic  neuritis.  There 
was  great  pain  in  the  feet,  the  worse  for  heat  and  dejoend- 
ency.  Also,  he  complained  of  girdle-pain  at  the  waist. 
Sensation  in  all  forms  Avas  normal  as  to  motion  ;  a  fine 
tremor  existed  throughout  upon  effort.  There  was  very 
quick    exhaustion,  but  no    other   distinct  loss  of   power. 

16 


1 32  ^'ER  VO  US  DISEASES. 

Temperature  and  electric  tests  were  difficult  and  objected 
to.  Faradic  reaction  in  the  arm-muscles  was  normal. 
The  same  current  in  the  leg-muscles  caused  no  motion  ;  a 
strouo-er  current  caused  general  convulsive  movement  of 
the  limb.     There  was  no  other  obvious  change.^ 

To  my  surprise,  I  learned  of  late  that  this  unfortu- 
nate gentleman  w^as  still  alive.  One  of  our  staff,  Dr. 
Burr,  has  visited  him  at  my  desire,  and  this  is  the 
present  history,  after  at  least  twenty-three  years  of 
varied  suffering: 

"The  patient's  condition  remained  the  same  from  the 
time  Dr.  Mitchell  last  saw  him  until  1883,  during  which 
year  the  redness  in  the  feet  slowly  disappeared  and  the 
pain  grew  less  severe  and  finally  became  a  mere  ache. 
There  has  never  since  been  a  return  of  the  color.  For 
some  years  the  legs  and  abdomen  have  felt  numb,  or,  as 
he  expresses  it,  he  is  '  dead  from  the  belly  down.'  He  has 
never  had  a  bedsore.  He  has  lost  flesh  during  the  last 
part  of  five  years,  but  at  times  increases  a  little  in  weight. 
He  lies  on  the  right  side  or  back,  with  the  eyes  covered 
by  two  bandages.  Lying  on  the  left  side  causes  pain  in 
the  left  shoulder.  The  room  is  kept  darkened.  He  has 
not  read  for  many  years ;  not  because  vision  is  bad,  but 
because  doing  so  causes  occipital  ache  and  nervous  feelings 
in  the  head.  The  voice  is  whispering,  and  so  low  that  he 
is  heard  with  difficulty.  There  is  remarkable  emaciation, 
the  abdominal  wall  almost  falling  against  the  spine.  The 
skin  is  very  pale,  but  the  mucous  membranes  are  of  fairly 
good  color. 

"As  he  lies  in  bed  the  feet  fall  forward  in  lax  exten- 
sion. He  can  flex  and  extend  the  toes,  ankles,  and  knees, 
and  adduct  and  abduct  the  thighs  while  the  legs  are  sup- 

1  See  American  Journal  of  the  Medical  Sciences,  July,  1878,  for  full  report. 


ER  YTHR  OMELA  L  GIA.  ]  83 

ported  by  the  mattress,  but  he  cannot  raise  the  legs  from 
the  bed.  He  can  move  the  left  arm  weakly  in  all  direc- 
tions, but  has  not  strength  enough  to  grasp  anything.  He 
cannot  feed  himself.  There  is  no  more  Avasting  of  the  legs 
than  of  the  rest  of  the  body.  Position  does  not  now  influ- 
ence the  color  of  the  extremities.  There  is  no  oedema  of  the 
feet.  The  skin-temperature  is  good  to  the  touch.  There 
is  no  rigidity  at  the  ankle-joint,  knee-joint,  or  thigh-joint, 
passive  motion  being  perfectly  free.  No  trophic  joint- 
lesion  is  present.  As  to  sensation,  he  localizes  touch  in 
the  legs  and  the  arm  perfectly.  Contact  is  often  felt  as 
pain,  more  so  in  the  legs  than  in  the  arm.  There  is  no 
more  pain  on  pressure  over  a  nerve  than  over  a  muscle. 
There  is  no  discoverable  swelling  of  the  nerve-trunks. 

''The  reflexes  in  the  legs  are  all  increased.  A  shght 
touch  on  the  soles,  and  at  times,  indeed,  on  any  part  of 
the  legs,  will  cause  the  member  to  be  quickly  and  forcibly 
drawn  up,  and  sometimes  the  movement  may  extend  to 
the  other  leg.  The  knee-jerk  is  quick,  large,  and  spastic. 
Clonus  is  present  in  both  feet,  and  at  times  patellar  clonus 
can  be  produced.  The  left  elbow-jerk  is  present,  but  not 
very  marked.  The  muscle-jerks  are  capricious.  Chin-jerk 
cannot  be  obtained. 

"The  bowels  are  moved  once  in  eight  or  ten  days,  always 
by  strong  purgative  medicine  or  mechanically.  He  never 
has  a  voluntary  stool.  He  cannot  hold  water  after  the 
desire  to  micturate  comes  on,  but  the  stream  is  good  and 
there  is  never  dribbling.  Sexual  desire  and  power  are  abol- 
ished. Examination  of  the  abdominal  and  thoracic  organs 
is  negative.  Sleep  is  variable  and  often  restless.  Violent 
jerking  of  the  legs  is  frequent  during  slumber.  He  now 
has  no  violent  pain  in  the  feet,  but  at  times  much  severe 
aching.  He  can  foretell  a  storm  by  increase  in  foot-pain 
and  shoulder-ache.  He  complains  much  of  queer,  inde- 
scribable feelings  in  the  head. 


1 84  ^EB  VO  US  DISEASES. 

''There  is  no  difficulty  iu  swallowing.  Appetite  is  vari- 
able. Mental  condition  is  good,  but  all  mental  effort  is 
disliked.  I  believe  that  at  the  present  time  an  hysterical 
element  is  added  to  his  organic  disease.  His  manner, 
voice,  and  head-symptoms  point  in  this  direction." 

On  April  13,  1893,  this  patient  died  in  Washington, 
and  to  my  regret  no  cadaveric  section  was  allowed. 

Seen  in  tiie  wisdom-yielding  light  of  many  years  this 
case  seems  to  have  been  originally  a  neuritis  of  peculiar 
type,  resulting,  as  time  went  on,  iu  the  addition  of 
hysteria  and  of  lasting  spinal  lesions  to  be  discerned  in 
the  clear  language  of  spastic  conditions,  excitable  re- 
flexes, clonus,  and  girdle-pains.  Neither  hysteria  nor 
the  added  spinal  malady  may  be  essential  features  of  the 
disease.  I  have  seen  them  in  other  cases,  not  alw^ays 
with  the  same  manifestations  as  here.  And,  on  the  other 
hand,  I  know  of  ery  thro  melalgias  of  milder  type,  which, 
after  twenty-five  years,  have  altered  little,  and  cer- 
tainly have  not  become  w^orse  or  added  a  single  spinal 
symptom.  The  old  age  of  a  case  may  really  be  of  more 
analytic  value  than  a  cadaveric  section.  In  K.  the 
neuritis  clearly  ceased  to  be  a  very  active  agency.  The 
sequent  spinal  malady,  probably  at  one  time  itsehP  a 
central  and  limited  neuritis,  remains,  and,  too,  the  hys- 
teria is  visible  enough.  And  now  let  us  turn  anew  to 
the  })resent  case.  Mr.  K.'s  case,  as  I  read  it  to-day, 
might  have  been  better  studied  in  1876.  I  did  not 
realize  its  importance.  I  lay  before  you  Dr.  Rhein's 
notes  of  the  present  case,  taken  in  my  ward.  Dr.  Burr 
has  also  given  it  his  careful  attention.  It  is  so  pure  a 
type  of  erythrotnelalgia  that  I  consider  it  most  desirable 
to  study  it  with  extreme  minuteness. 


ERYTHROMELALGIA.  185 

Case  LVIII. — T.  S.,  aged  tweuty-ODe  years,  a  stone- 
cutter, applied  for  treatment  at  Dr.  Goodman's  clinic  in 
February,  1893,  on  account  of  pain  in  the  right  foot  and 
difficulty  in  moving  it.  Dr.  Goodman,  promptly  recogniz- 
ing the  neurotic  element  in  the  case,  kindly  transferred  the 
patient  to  my  care.  The  family  and  personal  history  is 
negative. 

In  February,  1892,  the  patient,  with  several  other  men, 
was  raising  a  stone  weighing  between  ten  and  eleven  hun- 
dredweight, when  the  board  supporting  it  broke  and  one 
end  of  the  stone  fell  three  feet  and  struck  the  patient's 
right  foot  just  in  front  of  the  ankle-joint.  In  a  few 
moments  the  stone  was  removed.  The  patient  was  uncon- 
scious for  a  little  while.  After  about  an  hour  he  again 
became  unconscious  and  remained  so  for  four  hours.  The 
Avound  was  superficial  and  bled  very  little.  The  foot  and 
leg,  half-way  to  the  knee,  swelled  considerably.  The 
patient  was  kept  at  rest  for  four  days  and  hot  water  was 
applied  to  the  leg.  Six  weeks  later  a  large  swelling  upon 
the  sole  was  incised  for  the  relief  of  a  supposed  abscess. 
Little  bleeding  followed,  and  there  Avas  no  evidence  of  sup- 
puration. Ever  since  the  injury  there  has  been  difficulty 
as  to  motion  in  the  ankle,  owing  to  pain.  He  began  to  walk 
December  24,  1892.  The  swelling  did  not  disappear  en- 
tirely until  two  months  after  the  accident.  Walking  caused 
sharp  pain  under  the  internal  malleolus  and  just  in  front 
of  the  ankle-joint.  In  damp  weather  there  was  pain  in 
the  right  great  toe.  The  right  foot  felt  warmer  to  the 
patient  than  the  left.  The  effi)rt  to  walk  was  soon  given 
up  and  the  horizontal  position  permanently  assumed  as 
the  only  one  possible  to  be  borne. 

There  are  at  present  five  scars  due  to  the  injury  on  the 
dorsal  aspect  of  the  foot.  One,  1  cm.  by  1.4  cm.  in  size,  is 
situated  6  cm.  internal  to  the  median  line  of  the  foot  and 
9  cm.  below  a  line  connecting  the  malleoli.     The  second, 

16* 


1  §6  NER  VO  US  DISEASES. 

about  the  same  size,  is  7  cm.  to  the  inner  side  of  the 
first.  In  the  median  line  and  anterior  to  the  first  are  three 
smaller  scars  each  about  2  cm.  in  diameter.  They  are  all 
dark  purplish  and  hypersensitive  to  pressure.  He  is 
unable  to  stand  up,  or,  rather,  to  sustain  any  part  of  his 
weight  on  the  right  foot,  except  for  a  moment,  by  resting 
on  the  heel  alone. 

The  whole  of  the  right  foot,  as  he  lies  at  rest  supine, 
the  leg  being  extended,  is  slightly  redder  in  places  than 
the  left;  but  after  a  few  minutes  in  this  horizontal  position 
it  is  observed  that,  save  for  the  tint  of  the  scars,  the  feet 
are  indistinguishable  in  hue.  When  standing  erect,  with 
the  right  foot  hanging  down,  the  foot  becomes  flushed  at 
once ;  the  first  and  second  toes  assume  a  bright  red,  and 
this  extends,  appearing  here  and  there  in  islets  of  deepen- 
ing color  until  the  whole  foot  is  of  a  dark,  dusky  tint, 
which  becomes  more  pronounced  the  longer  he  is  up.  The 
upper  limit  of  redness  is  marked  by  a  dark-red  band  on 
the  ankle,  If  inches  above  the  lower  border  of  the  internal 
malleolus.  It  encircles  the  limb,  except  for  an  irregular 
space  on  the  outer  aspect. 

The  beginning  of  the  flush  in  the  j^endeut  foot  is  marked 
by  increase  in  the  size  of  the  veins  and  by  a  visible  and 
rapidly  augmented  force  of  arterial  pulsations.  It  is  a 
true  vascular  storm.  After  a  few  minutes  the  veins  re- 
main large,  but  the  arterial  throb  lessens ;  the  color  be- 
comes more  and  more  purplish,  but  even  after  a  half-hour, 
when  the  patient  stood  on  crutches,  was  never  of  the  smoky 
tint  seen  in  local  asphyxia.  When  again  put  at  rest  and 
supine  all  of  the  vascular  symptoms  disappeared  quite 
promptly.  The  whole  foot  is  over-sensitive  in  all  posi- 
tions. The  hypersesthetic  areas  diflfer  according  as  the  part 
is  level  or  pendent.  It  is  hypersensitive  to  a  needle- 
prick,  to  heat  and  to  cold,  and  to  pressure.  The  diagrams 
make  clear  the  facts  without  need  of  fuller  verbal  statement. 


bj: 


ERYTHROMELALGIA. 


187 


When  lying  on  a  level  slight  touches  give  no  pain,  but 
the  least  increase  of  pressure  hurts.  Pin-pricks  cause  ex- 
treme pain  ;  all  degrees  of  heat  or  warmth  are  over-appre- 
ciated up  to  the  knee.  The  same  degrees  of  heat  and  also 
of  cold  seem,  as  the  case  might  be,  hotter  or  colder  than 
they  appear  to  be  when  applied  to  the  other  leg.  This  is 
also  far  more  notable  when  the  tests  are  made  in  the 
flushed  areas. 

Fig.  3. 


There  is  constant  ache  of  the  right  foot,  even  when  at 
rest  on  a  level.  Motion,  passive  or  active,  makes  it  un- 
endurable. If  upright,  it  grows  far  worse,  and  he  at  last 
becomes  faint.  When  erect  the  least  touch  is  productive 
of  extreme  pain. 

The  outer  side  of  the  foot,  supplied  by  the  external 
saphena,  is  unaffected ;  and  this  is  true  of  the  heel,  which 


1 88  NEB  VO  US  DISEASES. 

is  supplied  by  the  plantar  cutaneous  branches  of  the  pos- 
terior tibial  nerve.  The  rest  of  the  plantar  surface,  sup- 
plied by  the  internal  and  external  plantar  nerves ;  the 
inner  surface  and  dorsum  of  the  foot,  supplied  by  the  in- 
ternal branch  of  the  musculo-cutaneous  nerve  and  the 
long  or  internal  saphenous  nerve ;  the  adjoining  sides  of 
the  great  and  second  toes,  supj^lied  by  branches  from  the 
anterior  tibial,  which  communicate  with  the  internal  branch 
of  the  musculo-cutaneous  nerve,  are  involv^ed.  The  area 
of  over-sensitiveness  on  the  posterior  leg  and  thigh  is  sup- 
plied by  the  small  sciatic.  The  light  shading  shows  the 
areas  sensitive  to  light  pressure,  while  the  dark  shading 
shows  the  area  sensitive  to  firm  pressure. 

The  drawing,  for  which  I  owe  my  thanks  to  Dr.  Taylor, 
represents  the  color  assumed  when  long  dependent. 

Motion.  The  power  over  extension  and  flexion  of  the 
foot  is  hard  to  study,  because  the  pain  inhibits  motion. 
At  rest  there  seems  to  be  power  to  move  the  ankle  and 
toes.  Above  the  knee  the  movements  appear  to  be  with 
normal  power. 

Dynamometer :  hand,  right,  158  ;  left,  155. 

There  is  marked  atrophy  of  the  calf-muscles,  chiefly 
involving  the  anterior  group.  The  circumference  of  the 
right  calf  5  cm.  below  the  tubercle  of  the  tibia  is  27.6 
cm.;  of  the  left  calf,  30.7  cm.  There  is  also  some  wasting 
of  the  vastus  externus  and  vastus  internus,  the  circumfer- 
ence of  the  right  thigh  a  few  inches  above  the  knee  being 
39.5  cm.,  while  that  of  the  left  thigh  is  42  cm. 

The  circumference  of  the  thigh  at  the  highest  point  is, 
on  the  right  side,  51  cm. ;  on  the  left,  50  cm. 

There  is,  when  at  rest,  a  fine,  rhythmical  tremor  involv- 
ing the  whole  leg,  and  when  circular  pressure  is  made  about 
the  calf-muscles  it  is  increased.  When  the  leg  is  long  ele- 
vated above  the  level  of  the  pelvis  this  tremor  gradually 
disappears.     Besides  this  there  may  be  observed,  occasion- 


ERYTHBOMELALGIA.  189 

ally,  clonic  spasms  of  the  flexors  of  the  first,  second,  and 
third  toes,  much  increased  as  to  number  and  force  when 
the  foot  hangs  down.  There  is  also  seen  a  fibrillary  tremor 
of  the  calf-muscles,  more  especially  posteriorly,  and  of  the 
posterior  thigh-muscles. 

The  foot  was  occasionally  re-examined  when  pendent. 
The  j)ain  varied,  as  did  also  the  color.  The  patient  says  it 
is  always  worse  in  bad  weather.  Finally,  the  foot  was  ele- 
vated on  an  inclined  plane,  forty  degrees,  for  three  weeks. 
This  rather  lessened  the  pain,  but  made  the  whole  posterior 
tibial  nerve  very  tender.  After  a  day  or  two  of  rest  at  a 
level  this  passed  away ;  nor  has  there  been  at  other  times 
sensitiveness  on  pressure  of  any  nerve-trunk  outside  of  the 
area  of  flushing. 

When,  at  the  end  of  three  weeks,  the  foot  Avas  permitted 
to  hang  down,  all  of  the  symptoms  at  once  returned  in  their 
utmost  severity. 

A  day  later  a  bandage  restricting  the  return  of  venous 
blood  was  put  on  at  various  levels  to  see  if  this  would  cause 
the  vascular  storm  seen  in  the  pendent  foot.  It  did  not. 
The  right  foot  scarcely  flushed  more  than,  under  like  cir- 
cumstances, does  the  normal  member. 

Reflexes:  Right  knee-jerk, -j — [-.  Spastic;  reinforcible 
by  M.  and  S. 

Left  knee-jerk,  normal. 

Ankle- clonus,  right,  six  or  eight  beats. 

Ankle-jerk,  right,  -| — |-.     Spastic. 

Ankle-jerk,  left,  normal ;  no  clonus. 

The  arm-reflexes  are  normal. 

Muscle- jerks :  Right,  below  knee,  excessive  as  compared 
with  left. 

All  skin-reflexes  are  normal. 

Electric  examination  (made  by  Dr.  Willits) : 

Far. :  Foot-extensors,  *  in.  coil,  right  leg ;  1  in.  coil,  left 
leg.     Foot-flexors,  f  in.  coil,  right  leg  ;  1  in.  coil,  left  leg. 


1 90  yER  VO  us  DISEASES. 

Extensors  (tibialis  ant.)  :  Galv.,  K.  cl.  c,  4  milli amperes, 
right  leg  ;  K.  cl.  c.,  5  milliamperes,  left  leg.  Flexors  :  An. 
cl.  c,  5  milliamperes,  right  leg ;  An.  cl.  c,  8  milliamperes, 
left  kg. 

There  is,  therefore,  quantitative  increase  in  the  leg- 
muscles  of  the  affected  side  ;  no  qualitative  change.  Sen- 
sation to  rapid  faradic  current  is  lessened  on  the  affected 
side. 

The  eyes  were  examined  by  Dr.  de  Schweinitz,  who 
found  vision,  pupils,  fundus,  form-  and  color-fields  all 
normal.  The  heart  has  a  faint  systolic  murmur  at  the 
apex.     The  lungs  are  normal. 

Examination  of  the  surface-temperature  of  the  legs  gave 
the  following  results :  mouth,  98.6°  F.  Legs  flat  in  bed 
— the  thermometer  on  dorsum  of  foot,  behind  great  and 
second  toe — right  foot,  95°  ;  left  foot,  87.8°.  Legs  hang- 
ing over  side  of  bed,  after  thirty  minutes :  right  foot,  95°  ; 
left  foot,  86.6^ 

Mouth,  101.8°  (patient  has  slight  pharjmgitis).  The  pa- 
tient being  flat  in  bed  :  right  foot,  96.8°  ;  left  foot,  94.6°. 
Legs  hanging:  right  foot,  95.8°;  left  foot,  92.6°. 

Repeated  examinations  were  made.  There  Avere  marked 
variations  of  temperature  in  both  extremities.  Once  both 
feet  were  colder  than  the  thermometers  would  register,  viz., 
86°  F.  The  affected  foot  was  always  the  warmer.  The 
temperature  fell  when  the  feet  were  pendent. 

Xo  record  of  treatment  is  here  added,  as  nothing  did 
good.  The  man  was  wonderfully  patient,  but  wore  a  look 
of  suffering  and  was  absolutely  free  from  hysteria. 

This  story,  as  told  in  Dr.  Rliein's  notes,  but  too  well 
illustrates  the  obstinacy  of  grave  cases  of  erythromel- 
algia,  and  accords  with  a  long  and  miserable  accumula- 
tion of  therapeutic  failures.  I  never  saAv  a  bad  case 
get  w^ell.     A  few  milder  examples  have  varied  much, 


ERYTHROMELALGIA.  191 

or  even  seemed  to  become  well,  or  remained  slight 
enough  to  be  borne.  I  know  of  one  case,  that  of  a 
woman  in  middle  age,  in  which  the  pain  and  flash, 
limited  to  the  dorsum  of  the  foot,  come  and  go,  seem- 
ingly without  cause.  Nothing  helps  her,  but  rest  in 
bed  is  unavoidable.  The  usual  treatments  have  failed 
in  this  present  case,  and  I  have  no  desire  to  repeat  what 
has  proved  valueless. 

Whatever  may  have  been  the  originative  cause  in 
other  cases,  here  there  is  a  clear  story  of  wound,  of 
the  peculiar  swelling  so  common  after  neural  injury, 
and  which  has  over  and  over  beeu  laid  open  as  an 
abscess  by  men  not  easily  deceived.  Then  there  is  the 
gradual  increase  of  tenderness  far  in  excess  of  that  seen 
in  ordinary  iuflammatiou.  I  am  of  opinion  that  we 
have  to  deal  Avith  a  neuritis  of  the  foot  caused  by  the 
wound. 

I  use  the  word  neuritis — nerve-end  neuritis — with 
more  or  less  of  doubt.  Some  such  distinct  affection  of  the 
smaller  nerves  does  seem  to  me  probable,  but  whether 
it  is  congestion,  neuritis,  or  some  other  of  the  unde- 
scribed  clianges  in  the  lesser  nerves  or  in  the  ultimate 
nerve-plates,  we  may  not  as  yet  decide  with  certainty. 
I  shall  return  later  to  this  question  of  neuritis.  We 
are  now  concerned  with  treatment.  I  have  confessed 
to  complete  therapeutic  defeat  in  all  my  previous  cases. 
It  seemed  to  me  that  it  would  in  this  man's  case  be 
reasonable  to  cut  the  nerves  which  are  as  to  motion 
unimportant,  and  to  do  this  near  to  the  foot,  and  as  to 
the  two  great  plantar  trunks,  to  stretch  these.  I  shall 
ask  Prof.  Keen  therefore  to  exsect  portions  of  the  in- 
ternal saphenous  and  musculo-cutaneous  nerves  and  to 
stretch,  as  I  have  said,  the  two  plantars.     These  meas- 


1 92  NER  VO  US  DISEASES. 

iires  ought  to  destroy  largely  feeling  on  the  dorsum  and 
the  inside  of  the  sole  and  dorsum,  and  by  the  stretching 
of  the  terminal  branches  of  the  posterior  tibial  much 
lessen  the  sensibility  of  the  sole.  The  anterior  tibial, 
if  one  may  trust  the  anatomies,  has  a  small  share  in 
the  innervation  of  the  foot;  but  the  inosculations  and 
interchange  of  nerve-fibres  are  such  that  I  may  find,  as 
one  does  in  the  hand,  that  a  section  by  no  means 
strengthens  one's  esteem  for  the  pictures  and  statements 
of  the  anatomist.  The  step  I  propose  has  not  been 
taken  before  in  this  disorder,  but  is  a  common  enough 
resort  in  truncal  neuritis.  My  hope  is  that  the  opera- 
tions I  contemplate  will  lessen  the  reflex  influences 
which  cause  the  vascular  congestion,  and  will  so  di- 
minish sensibility  as  to  permit  massage  to  be  painlessly 
employed. 

Dr.  Keen  operated  on  April  lOtli.  He  exsected  two  and 
one-half  inches  of  the  musciilo-cutaneous  nerve  and  the 
same  length  of  two  branches  of  the  internal  saphenous. 
The  two  end-branches  (plantar)  of  the  posterior  tibial 
nerve  were  stretched  at  the  internal  malleolus  with  a 
traction  of  fifteen  pounds  thrice  used.  The  result  next 
day  was  remarkable.  There  was  almost  immediate  relief. 
The  foot  could  be  squeezed,  pinched,  or  pricked  without 
pain.  Ansesthesia,  as  shown  by  the  accompanying  dia- 
gram, was  not  as  extensive  as  we  were  led  to  expect  it 
might  be.  The  day  following  operation  the  temperature 
of  the  feet  was  :  R.,  95°  F.;  L.,  93.5°  ;  mouth,  99.5°. 
On  the  right,  clonus  was  still  present  and  the  knee-jerk 
was  still  excessive.  The  wounds  healed  in  a  few  days. 
On  the  4th  of  May  the  patient  began  to  walk  on  crutches. 
Clonus  had  then  disappeared,  and  tlie  reflexes  were  no 
longer  exaggerated.  There  was  still  some  flushing  of  the 
foot  when  pendent,  but  no  pain  or  hypersesthesia.     When 


ERYTHROMELALGIA. 


193 


discharged  May  6th,  he  could  walk  well,  but  was  ordered 
to  continue  to  use  crutches  as  a  measure  of  precaution,  and 
had  also  a  bandage  applied  daily.  Dr.  Kyle  reports  cul- 
tures from  blood  and  nerves  obtained  at  the  operation  as 
yielding  purely  negative  results.^ 

Fig.  4. 


Sense  of  touch,  heat,  and 
cold  lessened  or  lost. 


On  May  12th  S.  reappeared  at  my  clinic.  He  was  able 
to  walk  a  little,  but  refrained,  at  my  request,  from  much 
use  of  the  legs.  The  flush  is  lessened  ;  the  arteries  do  not 
throb.  He  stands  and  moves  without  pain.  Above  all, 
the  temperature  of  the  pendent  diseased  foot  is  now  less 
than  that  of  the  left  member. 

June  7th  S.  is  reported  well  and  walking  easily  without 
crutches.  Six  months  later  he  was  at  his  Avork  as  a  stone- 
masop,  and  entirely  free  from  pain. 

The  tendency  of  recent  writers  seems  to  be,  as  I 
have  said,  toward  considering  erythromelalgia  as  a  neu- 
ritis.   But  suppose  we  accept  this  view,  and  in  the  light 


1  The  pieces  of  exsected  nerve  were  hardened  in  Mueller's  fluid  for  some 
weeks,  imbedded  in  celloidin,  and  stained  with  carmine.  On  microscopic 
examination  the  musculo-cutaneous  and  two  branches  of  the  internal 
saphenous  were  found  to  be  absolutely  normal. 

17 


1 94  NER  VO  US  DISEASES. 

of  the  two  cases  I  have  given  it  seems  more  than  prob- 
able, it  by  no  means  sets  the  matter  utterly  at  rest.  Neu- 
ritis is  becoming  a  sad  puzzle.  We  may  have  it  with 
paresis  and  little  pain;  we  may  have  it  without  notable 
paresis  and  with  horrible  pain.  It  exists  with  or  with- 
out myositis.  Again,  it  may  give  rise  to  causalgia, 
joint-troubles,  and  alterations  of  nails  and  hair.  It 
may  fail  to  disturb  nutrition  or  greatly  to  alter  local 
heat ;  and  lastly,  if  erythromelalgia  be  a  neuritis,  it 
may  cause  pain  and  flushing,  and  to  these,  increased 
enormously  by  dependency  of  the  part,  may  add  such 
a  rise  of  temperature  as  is  rarely  seen  in  acute  local 
inflammation. 

You  see  that  to  give  a  name  to  a  possible  cause  does 
not  always  help  us.  If  each  of  these  groups  of  symp- 
toms be  due  to  neuritis,  why  do  they  so  vary  ?  We 
may  conclude  that  the  nerves  are  subject,  like  the 
spine,  to  inflammations  affecting  only  certain  systems; 
but  in  the  nerves  the  fibres  of  sense  of  motion  and 
nutrition  and  vasal  control  are,  as  we  think,  scat- 
tered through  the  parent  nerve,  whence  it  seems  hard 
to  comprehend  the  possibility  of  isolated  inflammation 
of  systems.  And  yet  to  this  we  seem  driven.  The 
difference  in  effect  between  neuritis  of  a  trunk,  of  the 
minuter  nerves,  or  of  the  terminal  plates  has  not  as 
yet  been  fully  considered.  Certainly  the  constant,  gen- 
eral, deep,  and  surface  tenderness  of  erythromelalgia 
looks  to  me  much  like  a  condition  of  diff'used,  what  I 
might  call  terminal,  neuritis,  sure,  like  all  nerve- end 
maladies  or  influences,  to  cause  remote  reflex  eff'ects. 
The  exsected  nerves  taken  at  a  part  of  the  nerve-trunk 
within  the  flushed  area  show  no  signs  of  inflammation. 
We  may,  therefore,  conclude  that  erythromelalgia  is 


EEYTHROMELALGIA.  195 

not,  as  some  have  thought,  a  truncal  neuritis;  but  this 
very  negative  fact,  taken  with  the  symptoms,  makes 
more  probable  the  explanation  of  a  nerve-end  neuritis. 

Let  us  return  to  the  phenomena  which  follow  let- 
ting the  foot  hang  down.  The  man  is  seated.  He 
remarks  that  to  make  the  foot  very  red  he  must  stand. 
At  once  as  he  rises  the  tint  gets  a  brighter  rose,  and 
goes  on  as  before  described.  This  is  really  a  vascular 
storm,  and  soon  the  throbbing  of  the  vessels  is  less  vio- 
lent, and  the  temperature  falls  a  little  or  is  stationary. 
In  most  of  these  cases  pendency  causes  first  a  rise  and 
then  later  a  fall  of  the  mercurial  column.  In  this  man, 
as  in  some  others,  there  is  a  fall,  but  less  notable  on  the 
diseased  side. 

I  think  this  may  vary  with  the  age  of  the  disease. 
What  we  see  is  more  than  a  mere  vaso-motor  palsy.  If 
it  were  only  that,  we  could  with  ease  flush  the  foot 
when,  the  leg  being  horizontal,  we  tie  a  ligature  below 
the  knee.  You  have  seen  how  very  slightly  then  the 
foot  flushes.  The  upright  posture  and  the  long  column 
of  blood  seem  needed  to  get  a  great  effect. 

In  this  present  case  the  muscles  are,  as  to  motion, 
over-responsive  to  electricity,  and,  as  to  sensation,  but 
slightly  responsive  to  the  same  agency.  This  is  unusual. 
Indeed,  to  see  excess  of  response  in  disease  is  very  rare. 
Also,  there  is  some  wasting  in  these  over-irritable  mus- 
cles, and  this  adds  to  my  surprise  at  their  too  ready 
reply  to  the  battery  in  both  forms. 

Moderate  ankle-clonus  is  present  and  right  knee-jerk 
in  great  excess  as  a  spastic  reflex.  Altogether  the 
grouping  of  symptoms  is  uncommon. 

The  complex  symptom-group  here  considered  is  not 
easy  to   interpret,  especially   in  the  entire  absence  of 


196  ^ER  VO  US  DISEASES. 

hysteria.  Ordinarily — ajmrtfrom  the  erythromelalgia — 
the  signals  in  our  present  case  would  point  to  a  local 
spinal  and  not  extensive  lesion,  and,  remembering  some 
other  histories  of  erythromelalgia,  we  are  not  unpre- 
pared for  this  conclusion.  Even  then  the  riddle  is  but 
half-read.  Spastic  states  of  spinal  birth  do  not  yield 
excessive  electro-muscular  excitations,  or  swiftly  fail 
after  nerve-stretching  and  sections. 

It  is  to  be  remembered  that  only  the  older  cases  pre- 
sent these  quasi-spinal  symptoms  in  grave  forms.  Allan 
Sturges's  case  had  wasting,  with  only  quantitative  re- 
duction of  electric  excitability.  AYhether  clonus  and 
spastic  knee-jerk  are  ever  only  of  peripheral  neuritic 
origin  we  do  not  know.  AVhen  I  froze  my  own  ulnar 
nerve,  repeating  Waller's  experiments,  the  related 
nerves  and  muscles  acquired  for  a  time  a  wild  excess  of 
excitability  to  all  mechanical  impressions.  It  is  really 
an  open  question.  The  gradual  loss  of  clonus  after  the 
operation  and  the  lessening  of  the  spastic  quality  of  the 
knee-jerk  seem  to  me  interesting  and  rather  difficult 
to  explain. 

The  typical  form,  then,  of  erytliromelalgia  is  prob- 
ably a  painful  nerv^e-end  neuritis  with  or  without  co- 
existent inflammation  of  the  parent  stems.  Probably, 
too,  although  the  skin  may  be  of  normal  tint  when  the 
limb  is  at  rest,  the  deeper  tissues  are  always  too  full  of 
blood,  and  the  temperature  supra-normal.  Dependency 
only  exaggerates  these  conditions,  except  that  as  to  tem- 
perature it  does  not  always  do  so.  The  abrupt  lessening 
and  final  loss  of  pain,  local  fever,  hypersesthesia,  and 
flushing  under  the  influence  of  nerve-section  and  stretch- 
ing, make  it  seem  likely  that  some  of  these  symptoms 
are  reflex  from  excited  or  inflamed  nerve-ends.     When 


ER  YTHROMELALGIA.  \  97 

they  can  no  longer  play  miscliievonsly  on  the  centres 
they  are  in  turn  released  from  certain  of  the  morbid 
additions  which  stand  in  the  way  of  recovery.  I  have 
over  and  over  tried  to  bring  about  the  same  results  by 
hypodermatic  use  of  opium.  I  have  no  record  of  suc- 
cess, but  I  see  that  a  recent  case  is  said  to  have  been 
thus  helped. 

I  have  noticed  that  when  the  feet  are  pendent  the 
temperature  in  the  sound  foot  falls.  This  result  a  little 
surprised  me.  I  find  no  mention  of  it  elsewhere,  and 
we  shall  at  once  study  it  with  care;  as  a  fact  in  thermal 
physiology  it  may  be  of  interest. 

In  conclusion,  I  desire  to  add  that  I  have  seen  cases 
of  red  neuralgia  in  which  the  disorder  occurred  at  any 
part  of  the  surface  in  isolated  skin-spaces.  I  suspect, 
too,  that  in  another  species  there  are  end-inflamed  nerves 
in  some  of  the  viscera  and  in  the  muscles.  I  hope  in 
future  to  report  a  small  group  of  such  cases. 

I  add  to  these  cases  one  in  which  the  operation  for 
relief  of  this  interesting  disorder  resulted  in  gangrene 
and  death: 

Case  LIX.— April  7,  1894.  S.  M.  H.,  a  physician,  mar- 
ried, aged  forty-eight  years  ;  a  stout,  square-built  man,  with 
good  coloring  ;  always  well ;  worked  hard  in  full  practice. 
The  first  sign  of  the  present  trouble  occurred  in  August, 
1893,  during  a  holiday  in  camp.  After  considerable  exer- 
tion in  carrying  over  a  portage  he  felt  severe  burning  in  the 
fourth  toe  of  the  right  foot ;  but  within  a  day  this  passed 
away,  and  no  further  trouble  resulted  until  in  November  of 
the  same  year  he  slipped  and  wrenched  the  same  foot,  after 
which,  in  the  course  of  a  week,  severe  burning  pains  in  the 
sole  set  in.  These  were  not  constant,  but  came  and  went, 
growing  worse  by  degrees.    In  the  intervals  of  the  hot  pain 

17* 


198  NER  VO  US  DISEASES. 

there  was  much  aching  in  the  same  territory.  When 
the  exacerbations  of  pain  had  been  severe  the  ache  some- 
times extended  up  the  leg.  He  was  able,  however,  to 
stand  and  use  the  leg  a  little  in  going  about  his  work 
until  February  1,  1894,  when  he  found  that  standing 
increased  the  pain  so  much  that  he  was  obliged  to  give 
up  attempting  to  do  any  work  on  his  feet.  He  continued 
to  practise  as  far  as  he  was  able,  spending  much  time  at 
rest  in  a  supine  position  or  with  the  foot  raised  up  at  fre- 
quent intervals.  By  these  aids  he  succeeded  in  obtaining 
temporary  ease. 

At  present  the  leg  aches  if  long  in  a  dependent  position. 
The  foot  shows,  even  when  at  rest  and  the  patient  in  bed, 
more  red  and  white  mottling  than  is  usual  in  other  and 
similar  examples  of  disease.  This  varies  somewhat.  At 
the  date  of  examination  it  extends  as  described  from  the 
tip  of  the  little  toe  almost  to  the  middle  line  of  the  heel 
behind,  and  is  about  one  inch  in  width.  The  inner  side  of 
the  great  toe,  along  the  edge  of  the  nail,  has  a  faint  red 
blush,  not  nearly  so  deep  in  color,  and  from  about  the 
middle  of  the  calcaneum  at  the  side  of  the  heel  forward 
to  the  middle  of  the  arch  of  the  foot  on  the  inner  edge  is 
mottled  in  the  same  manner,  but  less  darkly.  There  is  a 
spot  over  the  inner  margin  of  the  metatarso-phalangeal 
articulation  of  the  little  toe,  which  is  red  and  of  about 
half  an  inch  in  breadth.  In  the  middle  of  the  metatarso- 
phalangeal articulation  of  the  big  toe  is  a  similar,  some- 
what larger  spot,  not  quite  so  darkly  red.  Wherever  this 
reddish  mottling  is  present  is  the  seat  of  pain,  and  the 
same  area  is,  at  its  worst,  exquisitely  hyper?esthetic  to 
touch,  but  somewhat  relieved  by  gently  applied  pressure. 
Throughout  this  territory  some  spots  are  more  sensitive 
than  others.  The  hypersesthesia  is  greatest  over  the  area 
described  as  at  the  base  of  the  little  toe  on  the  sole.  The 
spot  upon  the  base  of  the  great  toe  on  the  sole  is  very  sen- 


EB  YTHROMELALGIA.  \  99 

sitive.  The  tips  of  the  four  lesser  toes — not  the  pulps,  but 
the  extremities — are  also  very  tender,  but  do  not  show  the 
same  amount  of  redness.  These  characteristics  are  perhaps 
better  illustrated  by  the  diagram  than  by  my  description ; 
generally  the  intensity  of  tenderness  corresponds  to  the 
degree  of  redness.  The  line  between  tenderness  and  ordi- 
nary sensibility  is  not  very  sharply  defined. 

All  this  description  applies  in  a  far  less  degree  to  the 
foot  when  elevated.  Attacks  of  unbearable  pain  are 
brought  on  by  standing,  by  dependent  position  of  the 
limb,  by  warmth,  as  a  hot  summer-day ;  and  at  the  same 
time  the  hypersesthesia  is  increased.  Cold,  supine  posi- 
tion, and  elevation  of  the  leg  all  ameliorate  the  pain  and 
the  tenderness.  The  condition  of  the  weather  as  to  storms 
has  little  influence.     Passive  motion  gives  no  pain. 

The  measurements  of  the  foot  are  as  follows  :  Eight 
(affected  side),  around  metatarso-phalangeal  articulation 
(largest  point),  8f  inches;  around  instep,  9  inches.  On 
the  left  corresponding  points,  respectively,  8|-  and  8f 
inches — a  slight  difference,  the  increase  being  upon  the 
bad  foot. 

Standing  for  a  moment  or  two  somcAvhat  relieves  the 
pain  and  tenderness,  but  immediately  a  great  increase  of 
pain  results.  After  being  thirty  seconds  upon  his  feet  there 
is  a  marked  change  in  the  color  on  the  edge  of  the  foot, 
especially  on  the  little  toe  and  the  neighboring  joint,  the 
whole  becoming  a  livid,  deep,  mottled  red,  almost  jxirple  in 
places.  Both  sides  of  the  instep  sweat  a  little  after  stand- 
ing, and  there  is  then  greatly  increased  hypersesthesia. 
There  is  now  no  marked  throbbing  of  the  arteries  in  this 
position  or  after  it,  and  the  red  blush  does  not  seem  to 
spread  over  the  foot  much  beyond  the  outlines  of  redness 
seen  when  the  foot  is  at  rest  and  elevated ;  it  only  becomes 
far  more  marked.  Knee-jerk  is  excessive  upon  both  sides, 
more  on  the  right.     There  is  no  ankle-clonus  and  no  trace 


200 


NERVOUS  DISEASES. 


of  tenderness  of  the  nerves  up  the  leg.  The  dorsum  of  the 
foot  does  not  share  in  the  redness  or  tenderness  at  all. 
The  diagrams  and  colored  print  sufficiently  illustrate  the 
symptoms  I  have  described. 


Fig.  5. 


Outride  of  foot. 
Degree  of  tenderness  is  represented  by  depth  of  shading. 

The  patient  was  examined  repeatedly  and  with  the  utmost 
care  by  the  author,  by  Dr.  John  K.  Mitchell,  and  by  Dr. 
Morris  Lewis.  The  lungs  were  normal ;  the  heart  and 
vessels  at  the  wrist  and  elsewhere  were  apparently  free 
from   disease.     The   arterial   tension   was   not   in   excess. 


PLATE    II 


Foot  hanging  down  for  thirty  minutes.     (J.  M.  Taylor.) 


ERYTHROMELALGIA.  201 

There  was  no  arcus  senilis,  and  the  morning  urine  was 
normal.  That  passed  at  bedtime  shoAved  a  few  pus-cor- 
puscles— no  casts — and  once  a  faint  trace  of  albumin  with 
the  superposition  acid  test.  The  following  record  of  sur- 
face-temperatures shows  the  results  of  examinations  on  two 
consecutive  days : 

April  7, 1894.  Surface-thermometer  placed  over  the  very  red 
spot  on  sole  of  right  foot  near  base  of  little  toe. 

A.  Leg  held  horizontal  on  couch  20  min 31-/5°  C. 

Leg  placed  perpendicular  (foot  down)  10  min.      .       .    32V5°  C. 

Temperature  rose %°  C. 

The  foot  became  much  congested. 
Thermometer  then  placed  over  ball  of  great  toe. 

B.  Legnow  horizontal  for  20  min 35°  C. 

Leg  placed  perpendicular  10  min 353/^0°  C. 

Temperature  rose -/io°  C. 

April  8, 1894.  Thermometer  placed  over  dorsum  of  right  foot. 

C.  Horizontal  20  min 31°  C. 

Then  standing  10  min 3'^'^/&°  ^- 

Temperature  rose ^k°  C. 

Comparison  of  left  (unaffected  foot)  at  same  time  and  place. 

D.  Horizontal  20  min 29°  C 

Standing  10  min.' 2^°  C. 

Temperature  fell 1°  C. 

The  rise  of  temperature  here  apparent  in  the  foot 
when  hanging  down  and  the  patient  upright  on  crutches 
is  such  as  is  often  seen  early  in  cases  of  red  neuralgia. 
The  contrast  where  the  normal  left  foot  loses  heat 
when  the  patient  is  erect,  is  significant  of  what,  as  I 
have  shown  elsewdiere,  is  to  be  expected. 

There  seemed  to  me  no  doubt  as  to  this  case  being  a 
typical  example  of  erythromelalgia.  Nor  could  I  see 
why  I  should  not  recommend  with  confidence  the  oper- 
ation which  in  another  had  effected  a  radical  cure. 


202  ^ER  VO  US  DISEASES. 

The  j^atient  was  suffering  as  intensely  as  any  such  case 
within  my  experience,  and  there  seemed  no  reason  to  regard 
the  operation  as  serious. 

Accordingly,  on  April  12,  1894,  Dr.  T.  G.  Morton  oper- 
ated precisely  as  in  the  case  just  referred  to.  The  ether 
was  taken  without  the  least  difficulty.  An  incision  was 
first  made  over  the  ankle  and  the  musculo-cutaneous 
nerve  picked  up  and  excised  for  four  inches.  Next  the 
internal  saphenous  was  excised  for  five  inches  above  the 
ankle;  then  making  an  incision  four  inches  long  over 
the  posterior  tibial  nerve  behind  the  inner  malleolus, 
this  nerve  was  stretched  by  passing  the  curved  hook 
under  it  at  its  point  of  division  into  the  two  plantars. 
A  force  of  twenty-eight  pounds  was  applied,  as  shoAvn 
by  the  attached  scales.  The  incisions  were  closed  with 
continuous  silk  sutures,  dressed  with  sterilized  gauze,  and 
the  patient  put  to  bed  with  the  foot  elevated.  He  had 
considerable  pain  that  night  and  required  morphia. 
Stomach  remained  very  irritable  for  some  hours  after 
the  operation,  and  the  patient  became  very  nervous. 
Four  days  later  he  still  continued  to  be  excessively  ner- 
vous and  excitable,  and  had  much  pain  in  the  limb  and 
foot.  For  this  reason  it  was  impossible  to  test  sensation 
accurately.  He  could  feel  a  towel  passed  over  the  foot, 
however.  It  became  impossible  to  keep  the  foot  quiet  on 
account  of  his  extreme  restlessness  and  complaint  of  pain 
in  the  foot.  Finally  the  dressings  were  removed  and  cold 
applications  were  applied  with  some  relief. 

On  the  fourth  day  Dr.  Morton  became  uneasy  at  the 
absence  of  circulation  in  the  toes.  I  myself  was  out  of  the 
city,  and  the  case  was  for  a  time  altogether  in  the  hands 
of  the  very  skilled  surgeon  who  had  operated.  It  was  now 
becoming  plain  that  the  foot  was  threatened  with  gangrene. 
On  the  fifth  day  the  patient's  friends  announced  their  in- 
tention to  take  him   away  from  the   hospital.     This   was 


KR  YTHBOMELALGIA.  203 

done  despite  every  remonstrance.  Elsewhere,  a  week 
after,  an  amputation  was  attempted,  and  was  followed  by 
death  npon  the  operating-table. 

I  have  been  unable  to  obtain  full  details  of  the  later 
symptoms.  Circulation  was  arrested  in  the  foot  before 
he  left  us,  and  when  the  amputation  was  effected  there 
is  said  to  have  been  some  necrotic  disease  around  the 
lips  of  Dr.  Morton's  incisions.  I  understand  that  no 
post-mortem  section  was  allowed,  and  that  permission 
was  obtained  with  difficulty  to  examine  the  leg  after 
its  removal. 

I  am  indebted  to  Dr.  P.  S.  Hall  for  all  that  I  finally 
know  of  this  unfortunate  case.  At  the  second  opera- 
tion the  ether  was  taken  without  any  unusual  trouble ; 
but  suddenly  at  the  close  of  the  operation  the  patient 
became  livid,  breathed  with  difficulty,  and  died,  as 
has  been  related.  In  the  popliteals  a  long,  soft  clot 
was  found,  the  upper  extremity  of  which  showed  signs 
of  rupture  and  detachment.  There  was  probably  pul- 
monary embolism. 

All  the  vessels  of  the  amputated  member  showed ' '  thick- 
ening of  the  middle  coat "  (i.e.,  the  muscular  walls).  This 
obtained  in  even  the  smallest  arterioles  in  the  sole  of  the 
foot,  while  in  the  larger  vessels  here  and  there,  in  addition, 
were  calcareous  deposits. 

Further  histological  study  will  be  necessary  to  complete 
the  case.  It  is  to  be  remarked  that  Dr.  Burr  found  no 
change  in  the  portion  of  excised  nerve  removed  by  Dr. 
Morton. 

This  was  a  plain  case  of  erythromelalgia.  The  ex- 
amination of  sections  of  smaller  vessels  made  by  Dr. 
Hall  enabled  me  to  verify  his  statements.  Degenera- 
tive  changes  limited  to  these  lesser  vessels  are  rare, 


204  ^'ER  VO  US  DISEASES. 

nor  do  I  know  how  during  life  to  detect  them.  In 
the  absence  of  an  autopsy  the  remoter  causes  of  the 
final  disaster  must  remain  unknown.  As  to  operative 
relief^  I  think  that  in  the  future  I  should  stretch  all  the 
nerves,  and  leave  resection  of  their  trunks  to  be  resorted 
to  if  the  milder  means  gave  no  fortunate  results. 


CHAPTER  XI. 

NOTES   ON   SURFACE-TEMPERATURES   AS   AFFECTED 
BY    POSTURE   OF    LIMBS. 

I  REMINDED  you  last  Winter  of  the  endless  possibili- 
ties open  to  mere  observation  in  clinical  medicine  when 
pointing  ont  the  peculiarities  of  local  temperatures  in  a 
case  of  erythromelalgia. 

To  become  sure  as  to  general  temperatures  in  a  case 
of  disease  is  usually  easy,  requiring  only  ordinary  care 
and  good  thermometers;  but  to  get  surface-tempera- 
tures accurately  is  a  more  difficult  matter,  demanding, 
as  it  does,  more  time,  far  greater  care,  and  instruments 
that  as  yet  are  very  unsatisfactory,  either  because  they 
are  too  slow  in  registering  or  too  fragile.  I  commonly 
employ  the  coil-bulb  thermometer,  guarding  the  coil 
with  a  cork,  hollowed  so  as  to  roof  over  the  coil,  and 
perforated  to  admit  of  the  passage  of  the  stem.  The 
instrument  must  remain  long  on  the  part.  It  may  be 
kept  in  place  by  a  very  thin  caoutchouc  band,  split  so 
as  to  be  passed  over  the  tube,  and  arranged  so  as  to  lie 
lightly  around  the  limb  with  just  enough  pressure  to 
keep  it  in  place.  Thus  the  contact  is  kept  equally  the 
same,  and  in  comparing  the  two  members  great  care 
must  be  taken  accurately  to  repeat  this  and  other  con- 
ditions. If  the  pressure  be  too  great,  it  is  sure  to  affect 
for  a  time  the  thin  walls  of  the  bulb,  and  then,  as  the 
instrument  is  lifted,  the  column  instantly  falls  a  little, 
this  amount  representing  rise  from  excess  of  pressure. 
The  coil-bulbs  are  less  subject  to  this  source  of  error. 

18 


206  ^^^  yo  us  niSEASES. 

The  study  of  skiu-teraperatures  has  been  fairly  well 
made,  but  even  yet  may  gaiu  iu  accuracy  and  complete- 
ness. Moreover,  there  are  some  points  as  to  normal 
temperatures  rarely  considered  by  neurologists  in  com- 
paring the  heat  of  symmetrical  regions.  Certain  of 
these  have  come  out  clearly  in  the  study  made  during 
the  last  year  by  me,  and  under  my  direction,  by  the 
staff  of  the  Infirmary,  notably  Drs.  F.  S.  Pearce, 
Taylor,  Burr,  and  others. 

Minute  precautions  are  essential  in  dealing  with 
minute  differences,  and  in  fact  one  may  take  it  as  a 
rule  that  the  finer  the  instrument  the  finer  must  be  the 
human  instrument  using  it.  We  still  need  a  perfect 
surface-thermometer. 

As  the  rise  or  fall  in  cases  of  local  neuritis  may  be 
but  slight,  it  is  well  to  remember  that  normal  differences 
as  between  right  and  left  members  are  by  no  means  un- 
common. If,  for  illustration,  in  this  healthy  man  at 
rest  and  supine,  we  apply  the  surface-thermometer  and 
leave  it  at  least  ten  minutes  on  the  dorsum  of  the  right 
foot,  it  notes  35.6°  C,  and  on  the  left  35.2°  C.  Here 
is  a  fact  of  interest.  The  two  feet  are  not  always  alike 
in  temperature.  At  times  the  amount  of  difference 
is  1°  C.  Now  let  the  man  stand  up,  and  with  the 
thermometers  in  the  same  places  they  come  to  mark 
35.4°  C.  and  34. 9°  C.  respectively.  This  is  one  example 
taken  at  random.  Meanwhile  the  mouth-temperature 
has  remained  unaltered.  Certainly  this  is  an  interesting 
fact;  it  may  have  escaped  notice. 

Last  spring,  in  a  case  of  red  neuralgia,  we  were  meas- 
uring the  temperatures  of  the  feet  in  bed,  and  when 
hanging  over  the  edge,  or  when  dependent  from  the 
hips,  the  man  being  on  crutches.      In  the  acute  stage 


NO TES  ON  S UR FA CE- TEMPERA TURES.       207 

of  this  disease  dependency  of  limb  is  apt  to  cause  a  rise 
of  local  temperature;  but  in  the  case  in  question,  and 
perhaps  in  all  when  the  disorder  has  lasted  long,  there 
is,  under  these  circumstances,  a  fall  of  temperature  and 
not  a  rise. 

The  fall  in  this  case  led  me  to  study  anew  the  natural 
thermal  conditions,  and  after  personally  learning  that 
the  normal  foot  when  dej^endent  is  likely  to  fall  in 
temperature,  I  asked  Drs.  Taylor  and  Burr  to  test  the 
matter.  They  both  found  the  observation  to  be  correct 
in  themselves  and  in  several  of  our  nurses.  I  then 
asked  Dr.  Pearce  to  make  a  series  of  observations  on 
the  foot  and  hand.  These  have  been  made  with  care 
and  skilfully  varied.  To  save  space  I  give  the  figures 
in  tabular  form. 


- 

Time. 

Position  of  right  leg. 

Position 

of  left  leg. 

No. 

Horizontal.    Standing. 

Horizontal 

Standing. 

1 

P.M. 

35. 6^             35.4° 

35.5° 

34. 9° 

2 

p.  M. 

34.6                34.4 

34.6 

34.6 

3 

A.M. 

33. 6                32. 8 

33.6 

32.4 

4 

A.M. 

31.4                30.0 

31.6 

30.2 

51 

P.  M. 

34.4                34.0 

35.4 

33.4 

f) 

A.M. 

34.8                33.2 

34.0 

33.2 

7 

Noon. 

35.0 

35.0 

35.8 

35.6 

8 

p.  M. 

35.  6                34.  2 

35.8 

35.0 

9 

A.M. 

34.  2                33.  2 

34.6 

32.2 

10 

P.  M. 

33.6 

31.8 

34.0 

32.4 

111 

P.M. 

33.6 

31.0 

34.2 

30.4 

1  Experiments  5  and  11  were  performed  upon  two  old  cases  of  erythromel- 
algia  of  the  left  leg  in  men  twenty-one  and  thirty-four  years  of  age  respec- 
tively.   All  others  were  upon  healthy  persons. 


208 


NERVOUS  DISEASES. 


In  the  preceding  eleven  experiments  upon  the  dorsum 
of  both  feet  (at  the  same  time)  the  thermometers  were 
read  in  twenty  minutes,  as  the  subject  lay  supine;  then 
ten  minutes  later,  the  subject  standing  for  the  same 
length  of  time.  The  extremities  were  kept  uncovered 
and  away  from  draughts.  The  centigrade  scale  was 
used.     The  temperature  of  the  room  was  6^°  F. 

The  same  conditions  obtained  in  the  following  experi- 
ments upon  the  soles  of  the  feet: 


Time. 

Position  of  right  leg. 

Position  of  left  leg. 

No. 

Horizontal 

Hung  over 
edge  of 
couch. 

Horizontal. 

Hung  over 
edge  of 
couch. 

12        .        .        . 

A.M. 

33.6° 

33.2° 

34.0° 

33.8° 

13        .        .        . 

P.M. 

34.8 

31.4 

14        .        .        . 

P.M. 

36.0 

35.2 

15        .        .         . 

A.M. 

31.6 

30.6 

32.0 

31.0 

16        .        .        . 

A.M. 

30.8 

30.4 

29.0 

29.0 

The  same  conditions,  the  patient  lying  supine  contin- 
uously : 


No. 

Time. 

i           Palm  of  left  hand. 

Horizontal  on 
couch. 

Held  up  verti- 
cally. 

25 

p.  M. 

35.6° 

35.4° 

26 

P.M. 

34.6 

34.2 

27 

P.  M. 

35.2 

35.0 

28 

A.M. 

35.6 

35.4 

29 

A.M. 

35.1 

35.0 

30 

J 

A.M. 
P.  M. 

I        34.4 

84.0 

NO  TES  ON  S  URFA  CE-  TEMPERA  T  URES.       209 

The  conclusions  that  may  be  formulated  as  to  surface- 
temperatures  are  as  follows  : 

The  temperature  of  the  dorsum  and  sole  of  the  feet 
is  on  an  average  from  f  °  C.  to  1°  C.  less  when  standing 
erect  than  when  lying  horizontally. 

All  things  being  equal,  the  morning  surface- tempera- 
ture is  less  than  the  evening  surface-temperature  on  the 
dorsum  or  sole  of  the  feet. 

The  mouth-temperature  varies  little  as  between  lying 
down  and  standing;  or,  if  it  changes,  there  is  a  very 
slight  rise. 

The  nearer  the  trunk  the  less  do  the  surface-tempera- 
tures vary  in  different  portions  of  the  body. 

The  palms  of  the  hands  are  the  warmest  parts  of  the 
extremities;  their  surface  becomes  less  warm  as  the  ex- 
tremity is  moved  from  a  resting  horizontal  position  to 
one  of  hanging  down  loosely,  and  finally  to  being  held 
up  in  a  vertical  position. 

The  foregoing  obtains  whether  the  body  lies  supine 
or  is  held  erect. 

The  two  hands  or  the  two  feet  vary  somewhat  in  tem- 
perature in  the  same  person  under  apparent  equality  of 
conditions.  At  times  the  right  member  is  warmer;  at 
others  it  is  the  left. 


18* 


CHAPTER  XII. 

THREE   CASES   OF    REMAEKABLE   SPINAL   ANTERIOR 
CURVATURE   WITH    MENTAL    ABERRATION, 

I  SHOW  you  to-day  two  out  of  three  cases  of  some- 
what unusaal  character.  The  third  member  of  the 
group  I  haye  not  here.  You  canuot  fail  to  observe  at 
once  the  attitude  of  this  girl.  Let  me  ask  your  atten- 
tion to  this  sino-ular  case.  The  curvature  came  and 
grew  complete  within  a  few  months.  It  is  still  remark- 
able, and  was  far  more  so.  The  whole  spine  was  bent 
forward,  the  belly  protruded,  and  the  head  carried  back, 
to  enable  her  to  see  objects  on  a  line  with  the  eyes. 
There  was  no  possibility  of  straightening  her  either  by 
passive  efforts  at  suspension  or  through  volition,  but 
these  attempts  gave  rise  to  no  pain.  The  spine  seemed 
to  be  rigid,  and  she  could  neither  make  it  erect  nor  fully 
bend  to  one  side;  the  head  also  possessed  small  power 
of  rotation  or  flexion,  while  the  neck-muscles  were  not 
rigid.  With  the  gain  in  her  mental  state  these  peculiar 
symptoms  have  become  notably  less. 

This  description  also  applies  nearly  throughout  to  the 
man,  except  that  his  spinal  difficulty  was  altogether 
above  the  lumbar  region.  The  girPs  case  is,  no  doubt, 
largely  hysterical,  and  so  also  is  that  of  the  boy,  who 
had  in  an  extreme  degree  the  spinal  peculiarity. 

The  man's  condition  hardly  justifies  the  label  hys- 
teria; nor  did  that  of  two  others  alluded  to  later. 

Here,  then,  are  three  people — a  boy,  a  girl,  and 
a  man — all    more  or  less  insane,   and  all   showinir  a 


SPINAL  CURVATURE.  211 

disorder  of  the  vertebral  columu,  which  comes  with 
the  mental  state,  and  lessens  as  this  gets  better,  and  is 
not  due  to  appreciable  organic  disease. 

How  very  strange  are  the  postures  is  shown  in  Dr. 
Taylor's  sketches.  In  a  large  experience  of  all  forms 
of  mental  disorder  I  have  never  seen  elsewhere  any- 
thing just  like  these  in  the  pronounced  character  of  the 
curves  and  in  the  immobility  which  they  manifested. 

The  boy's  case  is  less  distinct,  but  the  resemblance  to 
the  others  suffices  to  justify  the  grouping.  Perhaps 
this  collection  of  symptoms  may  be  accidental.  The 
chance  grouping  together  of  symptoms  in  a  trio  of  cases 
may  readily  deceive  one  into  the  belief  that  we  have 
before  us  an  undescribed  clinical  type.  I  have  been 
patiently  reticent,  and  have  long  withheld  these  three 
cases  from  publication,  in  the  hope  of  seeing  others  like 
them,  which  might  permit  of  a  larger  numerical  com- 
parison. My  patience  has  not  been  rewarded  with  suc- 
cess, and  I  am  now  tempted  to  call  attention  to  a 
peculiar  set  of  symptoms,  with  the  hope  that  others 
may  contribute  like  cases  to  my  meagre  list,  so  that  a 
larger  experience  may  become  possible.  I  incline  to 
the  belief  that  the  cases  I  here  exhibit  illustrate  a  novel 
clinical  group,  which  may  be  non-hysterical  or  may 
assume  the  hysterical  type,  and  to  which  I  hesitate  as 
yet  to  affix  a  label. 

I  ought  to  say,  also,  tliat  in  the  past  I  have  met  with 
at  least  three  patients  who  had  this  collection  of  symp- 
toms ;  but  of  these  I  have  no  notes,  as  they  were  seen 
long  years  ago,  and  only  in  consultation. 

The  question  is  now  in  this  form:  Is  there  a  clinical 
type,  hysterical  or  not,  characterized  by  mental  failure, 
physical   weakness,    retinal    changes(?),    and    rapidly 


)^'l 


21 


NERVOUS  DISEASES. 


evolved  spiual  curvature,  extreme  iu  degree  and  other- 
wise unusual  in  type,  not  due  to  organic  vertebral  dis- 
ease? 

Case  LX. — F.  B.,  female,  thirteen  years  of  age,  was 
brought  to  my  clinic  April  4,  1890.  The  family  history 
is  negative.  The  child  was  born  at  term.  The  labor  was 
easy,  and  instruments  were  not  used.  She  Avas  breast- 
fed.    She  began  to  walk  at  thirteen  months,  and  to  talk  at 

Fig.  7. 


about  the  same  time.  She  has  never  had  any  serious  illness 
except  pneumonia,  seven  years  ago.  She  developed  well, 
mentally  and  physically,  until  about  eleven  months  ago, 
when  her  mother  noticed  that  she  had  fits  of  causeless 
crying  and  great  depression.  At  times  she  would  con- 
vulsively break  out  in  attacks  of  violent  anger.     "While 


SPINAL  CURVATURE.  213 

previously  she  had  always  beeu  number  one  in  her  school, 
she  soon  lost  all  interest  in  study,  fell  to  the  foot  of  the 
class,  and  finally  refused  to  go  to  school  at  all.  She  sits 
all  day,  careless  and  unconcerQed  as  to  what  is  going  on 
around  her.  She  will  have  nothing  to  do  with  her  old 
school-friends,  shows  no  affection  for  her  parents  or  brothers 
and  sisters,  and  never  speaks  except  in  answer  to  a  question, 
save  that  sometimes  she  talks  to  herself,  and,  as  if  under 
the  influence  of  an  hallucination,  will  cry  out,  "What  do 
you  want  ?"  ''Get  out  of  here,"  etc.  She  has  largely  lost 
the  sense  of  personal  cleanliness  and  is  dirty  in  her  habits. 

Her  general  bearing  is  striking.  The  abdomen  is  thrown 
forward,  the  shoulders  back,  the  right  one  being  much 
higher  than  the  left,  while  the  head  is  throw^n  forward, 
the  chin  at  times  resting  upon  the  chest.  The  left  thumb 
is  strongly  flexed,  the  forearm  j^ronated,  and  the  arm 
rotated  inwardly.  The  entire  spine  bends  stiffly,  and  it 
appears  impossible  for  her  to  stand  erect.  She  stands,  as 
shown  in  Fig.  8,  on  the  heel  of  the  right  and  the  toe  of  the 
left  foot.  There  is  no  evidence  of  spinal  bone-disease,  no 
angular  curvature,  no  pain  on  pressure,  no  sensitiveness  to 
heat  or  to  cold.  While  there  is  a  little  general  muscular 
weakness,  there  is  no  true  palsy,  and  except  for  slight  pallor 
she  is  well  nourished.  There  are  occasional  slow,  lateral 
movements  of  the  head,  and  the  hands  are  slowly  passed 
over  each  other.  Whether  these  movements  are  purposive 
or  automatic  cannot  be  determined.  The  fingers  of  both 
hands  can  be  passively  hyper-extended. 

Her  expression  is  fatuous  and  idiotic.  She  seems  to  take 
no  notice  of  her  surroundings,  and  is  absolutely  without 
interest  in  anything.  Her  replies  to  questions  are  silly ; 
her  speech  slow  and  somewhat  thick. 

She  sleeps  well  now,  but  formerly  slept  badly,  and  seemed 
to  fear  the  dark.  Menstruation  has  never  appeared,  though 
she  is  quite  well  developed.     Her  appetite  is  fair.     The 


2 1 4  NER  VO  US  DISEASES. 

urine  is  normal.     The  knee-jerk  is  slightly  large,  but  not 
spastic.     Sensation  is  normal. 

Dr.  de  Schweinitz  examined  her  eyes,  and  reports : 
"Concomitant  convergent  squint.  No  swelling  of  disc, 
but  there  is  a  diffuse  retinal  haze,  especially  marked 
above  and  below  the  discs.    Both  eyes  are  hypermetropic." 


Fig.  8. 


The  patient  was  seen  again  in  February,  1893.  Her 
mental  condition  was  even  worse  than  before.  She  never 
spoke  except  in  a  silly  fashion,  and  had  to  be  attended  to 
like  an  infant.  She  still  had  outbursts  of  anger.  Physi- 
cally she  was  in  about  the  same  condition  as  already  de- 
scribed, except  that  the  protrusion  of  the  abdomen  and 
the  large  anterior  curvature  of  the  lumbar  and  lower  dorsal 
spine  were  less  marked. 


SPINAL  CURVATURE.  215 

September,  1893.  She  has  steadily  but  slowly  improved 
since  the  last  date,  with  lessening  curvature,  but  the  gain 
in  the  physical  aspects  of  the  case  far  outstrips  the  gain  in 
the  mental  condition.     The  eye-grounds  are  better. 

She  continued  to  improve  physically.  The  back  lost  its 
curve,  the  belly  became  as  to  form  natural,  the  head 
assumed  a  natural  position,  and  very  much  more  slowly 
she  recovered  her  health  of  mind,  and  is  now  considered  to 
be  as  well  as  before  the  onset  of  this  singular  malady. 

Case  LXI. — L.  W.,  male,  twenty-five  years  old,  mar- 
ried, a  mill-hand,  came  to  the  clinic  November  22,  1889. 

The  family  history  is  negative.  The  patient  denies  vene- 
real disease,  and  no  evidence  of  it  is  discoverable.  He 
has  used  no  liquor  and  tobacco  only  moderately.  He 
had  always  been  well  until  June,  1888,  when  his  employer 
discharged  him  on  the  ground  of  mental  unfitness  for  work. 
He  complains  of  backache  and  headache.  He  says  that 
he  often  hears  voices  of  invisible  people  talking  to  him, 
but  he  cannot  remember  what  they  say.  He  denies  that 
he  ever  gets  despondent,  and  is  totally  unconscious  of  any 
mental  trouble. 

His  general  bearing  is  precisely  similar  to  that  of  the 
first  case  described.  The  head  is  kept  flexed  on  the  breast, 
the  eyes  wide  open,  the  dorsal  curve  and  rigidity  most  re- 
markable ;  nor  could  they  be  altered  by  effort,  voluntary 
or  passive.  The  gait  is  shuffling  and  slow,  and  the  right 
foot  is  much  everted.  Station  is  good.  The  knee-jerk 
is  large,  but  not  spastic.  Sensation  is  normal.  There  is 
no  paralysis. 

His  expression  is  dull  and  sleepy.  Mentally  he  is  stupid. 
He  understands  what  is  said  to  him,  and  replies  intelli- 
gently, but  often  his  statements  cannot  be  relied  on.  He 
will  unwittingly  falsify.  He  has  lost  all  interest.  His 
inability  to  work  is  evidently  due  to  mental  insufficiency, 
and  not  to  the  pain  of  which  he  complains.     He  is  harm- 


216  NERVOUS  DISEASES. 

less  and  never  subject  to  fits  of  anger ;  and,  on  the  other 
hand,  he  is  without  affection.  In  other  words,  he  is  in  a 
condition  of  dementia. 

The  abdominal  and  thoracic  organs  are  normal.  The 
eyes  were  examined  by  Dr.  de  Schweinitz,  who  reports 
that  there  is  a  slight  retinitis. 

He  was  seen  again  some  months  later,  in  the  spring  of 
1890,  and  had  improved  sufficiently  to  do  odd  jobs,  but 
was  still  unfit  for  continued  work.  The  spinal  curve  was 
far  less  and  the  mobility  nearly  normal.  The  eyes  were 
reported  to  be  materially  better.  He  was  far  more  cheer- 
ful, and  observed  with  interest  that  he  was  much  more 
erect  and  did  not  have  to  tilt  his  head  back  and  lift  his 
lids  to  get  a  full  view  of  the  faces  of  people.  At  this  time 
there  was  a  complete  re-examination,  which  added  nothing 
to  the  simple  statements  already  made.  He  continuously 
improved,  and  I  was  informed  made  a  complete  recovery. 

Case  LXII. — L.  R.,  male,  sixteen  years  of  age,  was 
sent  by  Dr.  Pearce,  of  Steubenville,  Ohio,  in  March,  1890. 
The  family  history  is  negative.  The  j^atient  suffered  no 
injury  at  or  near  birth.  He  has  never  had  convulsions  or 
any  other  serious  acute  illness.  He  has  always  been  very 
retiring,  seldom  speaking  unless  spoken  to,  never  mirthful, 
averse  to  society,  and  not  fond  of  amusement.  He  attended 
the  public  schools  for  six  or  seven  years,  but  Avas  always 
careless  and  indifferent  about  his  studies,  and  as  time 
passed  grew  duller  and  duller.  About  two  years  ago  his 
comrades  annoyed  him  so  much  that  he  was  taken  from 
school,  and  for  a  while  he  was  taught  at  home.  Finally, 
however,  all  efforts  at  education  had  to  be  abandoned. 
He  still  possesses  intelligence  enough  to  read,  but  rarely 
does  so.  He  understands  perfectly  all  that  is  said  to  him, 
but  is  morose  and  irritable.  He  cries  a  great  deal,  and  is 
without  affection.  He  is  extremely  disobedient  and  with- 
out fear  of  punishment.     He  protests  that  there  is  nothing 


SPINAL  CURVATURE. 


217 


the  matter  with  him  ;  says  dramatically  that  he  will  live  a 
thousand  years,  and  that  he  wants  to  be  left  alone.  He 
often  gets  upon  his  hands  and  knees  on  the  floor,  and, 
turning  his  head  in  an  objectless  manner  toward  the  ceil- 
ing, remains  so  for  a  considerable  time.  His  usual  posi- 
tion is  sitting  with  the  thighs  strongly  flexed  on  the  abdo- 
men, the  legs  flexed  on  the  thighs,  the  arms  clasped  around 


Fig.  9. 


the  legs,  and  the  head  down, with  the  chin  resting  upon  the 
knees.  This  knotted  position  he  maintains  for  hours.  At 
times  he  suddenly  rises,  hops,  or  runs  around  the  room, 
whining  the  while,  always  going  to  the  left  if  he  meets  a 
table  or  chair  or  other  obstruction.  He  will  stop  suddenly, 
jump  up  and  down  many  times,  frowning  and  looking 
horror-stricken,  and  then  walk  away  and  sit  down  in  his 

19 


218  NERVOUS  DISEASES. 

accustomed  attitude.  He  objects  much  to  being  touched, 
saying  that  it  hurts  him ;  but  deep  pressure  does  not  give 
so  severe  pain  as  a  light  touch.  His  hypersesthesia  is  men- 
tal, not  peripheral.  He  is  reluctant  to  talk  to  any  one,  or 
even  to  answer  a  question ;  and  when  he  does  so  he  repeats 
words,  a  clause,  or  even  a  sentence  several  times,  so  that 
frequently  it  is  difficult  to  comprehend  what  he  says.  He 
is,  however,  sometimes  boisterous,  and  will  swear  roundly 
and  scold  every  one  around  him,  and  squirm  and  jump  and 
throw  himself  about,  and  finally  fall  to  the  ground  ex- 
hausted, panting  for  breath,  grasping  at  his  chest  as  if  in 
deadly  fear  of  suffocation.  He  complains  bitterly  of  new 
clothing,  saying  that  it  is  too  tight  and  binds  him.  He 
has  great  trouble  in  dressing  and  undressing,  but  objects 
strongly  to  being  assisted.  He  will  apparently  forget  what 
he  is  doing ;  will  put  on  a  shirt  and  not  remember  that  a 
coat  should  follow.  The  same  peculiarity  is  shown  in  eat- 
ing. It  is  no  unusual  thing  for  him  to  sit  at  the  table  for 
hours  muttering  to  himself,  and  only  now  and  then  taking 
a  mouthful  of  food.  So  bad  is  this  that  he  sometimes 
suffers  from  want  of  nourishment.  He  goes  to  stool  of  his 
own  accord,  but  may  be  found  thus  engaged  hours  after- 
ward. The  character  of  his  sleep  varies  much  ;  sometimes 
it  is  quiet  and  restful,  at  others  much  broken. 

The  illustration  shows  well  the  peculiarities  of  his  usual 
position  when  standing.  The  legs  are  slightly  flexed  at  the 
knees,  the  abdomen  thrown  forward,  and  the  shoulders 
rounded.  There  are  increase  in  the  normal  antero-posterior 
spinal  curvature  and  slight  left  lateral  curvature.  There 
is  no  evidence  of  bone-disease.  He  stands  with  the  legs  in 
partial  flexion.  This  bending  can  be  overcome  by  passive, 
but  not  by  active  motion,  and  the  spine  can  by  no  means 
be  straightened.  The  skin  is  yellowish  and  harsh.  The 
knee-jerk  is  lessened,  but  distinctly  reinforcible.  The  tho- 
racic and  abdominal  organs  are  normal.    Careful  watching 


SPINAL  CURVATURE.  219 

has  failed  to  detect  evidence  of  masturbation.     The  eyes 
appear  to  be  normal. 

When  heard  from,  three  years  later,  he  had  improved 
considerably,  the  change  coming  on  rather  suddenly  in 
JMarch  of  this  year.  He  said  one  day  that  he  had  been 
out  of  school  so  long  that  he  would  be  behind  the  boys,  and 
asked  for  his  books.  A  teacher  was  obtained  for  him,  and 
he  became  obedient  and  cheerful  and  desirous  to  study. 
The  gain  has  been  happily  continuous,  and,  as  in  the  other 
cases,  the  change  in  carriage  and  the  lessening  of  spinal 
immobility  have  gone  on  as  the  mental  state  has  become 
clearer. 

I  find  it  more  than  merely  difficult  to  discuss  these 
three  cases.  They  seem  to  me  to  belong  to  one  group ; 
but  if  in  my  ample  experience  I  can  recall  but  two  or 
three  like  them,  I  think  we  must  concede  them  to  be 
of  extreme  rarity.  Perhaps  my  report  may  lead,  as 
usual,  to  the  publication  of  other  examples  of  what  I 
am  inclined  to  regard  as  a  very  distinct  clinical  genus. 


CHAPTER   XIII. 

CONCERNING  THE  HISTORY  OF  THE  DISCOVERY  OF 
REFLEX  OCULAR  NEUROSES,  AND  THE  EXTENT  TO 
WHICH   THESE   REFLEXES   OBTAIN.^ 

As  skilled  ophthalmologists,  you  must  be  aware  that 
you  touch  the  general  practice  of  medicine  at  many 
points,  and  very  often  are  most  helpful ;  but  sometimes, 
because  of  being  satisfied  to  think  only  of  the  eye,  may 
quite  fail  to  be  as  helpful  as  you  might  be. 

Nowadays,  except  for  obvious  eye-trouble,  you  are 
most  likely  to  be  consulted  as  concerns  headaches,  and 
to  be  asked  if  they  are  in  this  or  that  case  the  offspring 
of  disorders  of  the  visual  apparatus.  Very  frequently 
the  patient  goes  directly  to  you,  so  that  you  become  his 
only  adviser,  and  it  is  as  to  this  form  of  undivided 
responsibility  that  I  shall  have  to  speak  before  I  close; 
for  it  is  here  that  you  sometimes  fail  to  grasp  the  truth 
that  he  who  has  properly  corrected  the  eye  may  have 
left  undone  that  Avithout  which  his  work  loses  much  of 
its  value. 

Before  dealing  with  this  and  other  more  practical 
matters,  I  should  like  to  call  your  attention  to  the  gen- 
eral history  of  the  connection  of  headaches  and  other 
neuroses  with  eye-strain.  I  am  the  more  interested  in 
doing  this  because  I  had  a  personal  share  in  directing 
the  attention  of  the  medical  public  to  this  matter,  and 


1  An  abstract  of  remarks  before  the  Ophthalmologic  Section  of  the  College 
of  Physicians  of  Philadelphia,  March  26,  1894. 


REFLEX  OCULAR  NEUROSES.  221 

also  because  it  is  my  belief  that  we  of  this  city  were  the 
first  to  bring  this  relation  into  large  practical  prom- 
ineDce. 

I  am  under  the  impression  that  Dr.  Ezra  Dyer  and 
Dr.  J.  Haskett  Derby,  of  Boston,  were  the  first  Amer- 
icans to  bring  us  home  from  Germany  modern  views  as 
to  corrections  to  be  accomplished  in  disorders  of  the 
optic  apparatus. 

Dr.  Dyer  came  here  to  live  in  1862.  From  this 
accomplished  oculist  I  learned  a  great  deal  in  regard 
to  the  treatment  of  the  eyes,  and  it  was  through  certain 
cases  thrown  into  his  hands  by  me  that  I  came  first  to 
apprehend  more  fully  the  mischief-making  capacity  of 
imperfect  eyes. 

I  remember  with  great  distinctness  the  earlier  of  the 
many  important  cases  I  saw  with  Dr.  Dyer.  Some  of 
them  made  a  serious  impression  upon  my  mind.  One 
was  that  of  a  young  woman  whom  I  had  known  for 
many  years  to  have  exceedingly  disordered  eyes,  and  to 
be  unable  to  use  them  for  more  than  a  minute  at  a  time 
without  pain.  She  suffered  a  great  deal  from  headache, 
but  although' she  had  seen  many  physicians,  neither  they 
nor  I,  nor  Dr.  Dyer  (whom  she  consulted  as  to  her 
eyes),  had  any  suspicion  that  the  eyes  were  almost  the 
sole  factor  in  the  product  of  pain.  The  headaches  were 
entirely  occipital.  Dr.  Dyer  carefully  glassed  this 
young  woman,  merely  to  aid  her  vision,  and  shortly 
afterward,  in  some  two  or  three  months,  she  told  me 
that  her  headaches  had  entirely  disappeared,  but  that 
they  returned  if  from  any  cause  she  was  without  her 
glasses  for  a  few  days. 

This  fact  struck  me  very  forcibly.  Shortly  afterward 
I  met   in    consultation   the  late  Dr.  John  F.  Meigs, 

19* 


222  ^EB  VO  US  DISEASES. 

concerniDg  the  case  of  a  young  widow  who  had  suffered 
for  many  years  with  extreme  headache,  pain  down  the 
spine,  and  also  Avith  Avhat  at  that  time  I  considered  as 
hysterical  spasmodic  retraction  of  the  head.  After  we 
had  talked  the  case  over,  Dr.  Meigs  said  to  me  that  his 
medical  resources  were  exhausted  as  to  this  case,  and 
that  he  did  not  know  what  caused  the  headaches.  I 
then  asked  if  they  might  not  possibly  be  due  to  what 
at  that  time  I  was  bes^innino;  to  call  "  eve-strain. '' 
He  said  it  was  possible,  but  that  he  had  never  met  with 
or  heard  of  such  a  thing.  I  got  his  ready  consent  to 
refer  his  patieut  to  Dr.  Dyer.  Careful  correction 
promptly  relieved  these  headaches.  The  stiffened  mus- 
cles at  the  back  of  the  neck  relaxed,  and  four  months 
afterward  this  woman  was  in  better  health  than  she  had 
been  since  childhood.  These,  and  other  cases,  at  last 
opened  my  mind  to  a  distinct  conception  of  the  fre- 
quency of  the  relation  between  disorders  of  the  appa- 
ratus of  the  eyes  and  headache  or  other  neuroses. 

As  Dr.  Dyer's  practice  enlarged,  and  as  physicians 
began  to  have  increasing  confidence  in  the  modern 
methods  of  correcting  the  eyes,  I,  too,  learned  still  more 
of  these  interesting  difficulties.  I  think  the  knowledge 
that  a  headache  might  be  due  to  ocular  troubles  was 
becoming  pretty  well  diff'used  among  the  more  intelli- 
gent of  the  profession  in  Philadelphia,  when,  in  the 
Medical  Reporter,  in  1874,  in  writing  of  headaches,  I 
described  headaches  from  eye-strain,  and  gave  several 
cases  at  length.  These  cases  were  corrected  by  Dr. 
Thomson.  The  cases  seen  with  Dyer  occurred  as  early 
as  from  1862  to  1864;  I  cannot  more  surely  set  the 
dates.  I  then  got  the  impression,  which  I  still  retain, 
that  hemicrania  of  the  classic  type,  although  it  may  be 


REFLEX  OCULAR  NEUROSES.  223 

increased  and  made  ^\'orse  by  ophthalmic  defects,  rarely 
owes  its  existence  to  this  alone,  and  that  headaches  of 
eye-strain  are  usually  of  quite  different  type. 

I  did  not  again  write  on  the  subject  until  1876.  In 
April  of  that  year  I  published  a  paper  in  the  American 
Journal  of  the  Medical  Sciences.  I  there  stated  the 
following  conclusions,  having  learned  that  not  only 
headaches,  but  vertigo,  nausea,  anaemia,  and  much 
disturbance  of  the  general  health  might  be  due  to  im- 
perfect eyes.  At  that  time  I  summed  up  my  opinions 
as  follows  : 

1.  That  there  are  many  headaches  which  are  caused 
by  disorders  of  the  refractive  or  accommodative  appa- 
ratus of  the  eye. 

2.  That  in  some  instances  the  brain-symptom  is  the 
most  prominent,  and  sometimes  the  sole  prominent 
symptom  of  the  eye-troubles ;  so  that  while  there  may 
be  no  pain  or  sense  of  fatigue  in  the  eye,  the  strain  with 
which  it  is  used  may  be  represented  by  occipital  or 
frontal  headache  only. 

3.  That  the  long  continuance  of  eye-trouble  may  be 
the  unsuspected  source  of  insomnia,  vertigo,  nausea,  and 
general  failure  of  health. 

4.  That  in  many  cases  the  eye-trouble  becomes  sud- 
denly mischievous,  owing  to  some  failure  of  the  general 
health,  or  to  increased  sensitiveness  of  brain  from  moral 
or  mental  causes. 

It  may  be  somewhat  interesting  to  carry  the  history 
of  the  subject  beyond  this  point.  The  knowledge  of 
which  I  speak  is  perhaps  one  of  the  most  valuable  con- 
tributions to  the  relief  of  human  suffering  that  has  been 
made  during  the  century.  It  is  impossible  to  give  the 
credit  of  this  vast  gain  to  any  one  man,  and  to  say  with 


224  NERVOUS  DISEASES. 

truth  that  it  was  due  to  him  alone.  Hehnholtz^  Don- 
ders,  and  von  Graefe  made  this  relief  possible  by  their 
scientific  work ;  but  neither  in  Europe  nor  here  was 
there,  so  far  as  I  know,  in  1862,  or  much  later,  any 
practical  conception  among  either  oculists  or  physicians 
as  to  the  frequent  power  of  bad  eyes  to  create  headache 
and  divers  other  troubles.  No  physician  then  sent 
headache-cases  to  an  ophthalmic  surgeon,  and  my  paper 
of  April,  1876,  was,  I  think,  the  first  contribution  of 
importance  to  this  subject  made  from  the  standpoint 
of  the  general  practitioner. 

In  fact,  one  looks  in  vain  for  many  a  day  through 
the  text-books  on  the  eye,  and  the  monographs  on  head- 
ache, for  a  statement  of  the  imperative  need  to  study 
the  eyes  in  headache,  vertigo,  etc.  If  here  and  there 
we  find  a  sagacious  ophthalmologist  speaking  of  the 
distress  and  pain  which  manifest  ocular  trouble  occa- 
sions, the  general  text-books  are  silent  as  to  a  practical 
hint,  and  the  profession  at  large  remains  ignorant. 

Quite  recently,  in  1886,  there  appeared  Ernest  Clark's 
book  on  Eye- strain,  and  here  is  full  confirmation  of 
what  I  state,  and,  too,  of  Dr.  Clark's  entire  failure 
to  make  clear  our  share  in  the  valuable  discovery  I 
am  discussing.  This  author  points  out  that  fifty  years 
ago  Tyrell,  in  speaking  of  asthenopia,  very  well  de- 
scribed its  power  to  cause  headache,  dyspepsia,  vomiting, 
diplopia,  vertigo,  and  palpitation.  He  even  employed 
the  term  ^^  eye-strain,^ ^  its  first  printed  use,  I  suspect, 
in  connection  with  this  subject. 

I  find  in  Dr.  George  Stevens's  book  on  Functional 
Nervous  Diseases,  published  in  1887,  information  which 
enables  me  to  carry  forward  the  history  of  this  subject. 
He  says,  page  8:  ^^  No  general  principle  of  sympathetic 


B.EFLEX  OCULAR  NEUROSES.  225 

or  reflex  irritation  had,  however,  been  formulated,  and 
the  first  printed  announcement  of  the  existence  of  such 
a  principle  was  made  by  myself,  in  a  paper  presented 
to  the  Albany  Institute  in  the  early  part  of  1876'' 
(On  Some  Results  of  the  Anomalous  Refraction  of  the 
Eyes).     It  is  difficult  to  understand  this  claim. 

The  paper  to  which  Dr.  Stevens  alludes  here  as  pre- 
sented to  the  Albany  Institute  was  read  by  title  before 
the  Institute,  May  30,  1876,  and  placed  on  file  to  be 
presented  thereafter;  but  I  do  not  find  it  anywhere 
stated  in  the  Transactions  or  Proceedings  of  the  Albany 
Institute  that  it  was  ever  read  or  printed. 

Soon  afterward  a  paper,  by  the  same  author,  was  read 
before  the  Academy  of  Medicine  in  New  York,  June 
15th  of  the  same  year  (Refractive  Lesions  and  Func- 
tional Nervous  Disorders).  This  paper  deals  with 
the  question  of  chorea  chiefly.  Dr.  Stevens  attributes 
a  very  large  proportion  of  choreal  cases  to  hyperme- 
tropia.  As  to  this  matter  I  shall  have  more  to  say 
before  I  close. 

In  the  New  York  Medical  Record,  September,  1876, 
there  is  also  a  paper  by  Dr.  Stevens  upon  the  Rela- 
tions between  the  Anomalous  Refraction  of  the  Eyes 
and  Certain  Functional  Diseases  of  the  Nervous  Sys- 
tem, with  a  table  showing  the  refractive  condition  of  the 
eyes  in  fifty-four  cases  of  epileptic  and  insane  persons. 
This  paper  deals  w^ith  the  fact  that  refractive  errors  are 
common  in  cases  of  epilepsy  and  the  like,  and  with  the 
great  frequency  with  which  refractive  anomalies  have 
been  found  in  connection  with  recurrent  headache.  As 
to  this  matter,  too,  we  have  the  later  papers  of  both  Drs. 
Stevens  and  Ranney,  concerning  which  I  shall  also 
have  a  few  words  to  sav. 


226  ^^ER  VO  US  DISEASES. 

I  find  later,  in  the  New  York  Medical  Journal  for 
June,  1877,  a  paper  by  Dr.  Stev^ens  (Light  in  its 
Eelation  to  Disease),  which  I  presume  is  the  same  as 
one  presented  to  the  Albany  Institute  December  19, 
1876.  It  deals  chiefly  with  the  question  of  heredity  in 
connection  with  faulty  refraction  of  the  eyes  and  other 
matters. 

In  looking  over  the  later  history  of  this  matter  I 
find  that  certainly  one  of  the  earliest  distinct  papers  on 
the  subject  of  astigmatism  as  causing  headaches  was 
written  by  Dr.  William  Thomson  in  1879/  After  this, 
papers  began  to  multiply  in  the  eighties;  but  long  before 
the  general  medical  public  had  the  least  idea  of  this 
valuable  discovery,  these  two  gentlemen  (Drs.  Thomson 
and  Dyer)  had  obtained  a  clear  and  practical  grasp  of 
the  facts  in  question. 

So  much  for  the  history  of  this  matter;  it  has  become 
an  old  story. 

ISTow,  the  e very-day  practitioner  called  upon  to  treat 
a  neurosis,  especially  a  headache,  habitually  refers  the 
patient  to  an  ophthalmologist,  and  does  not  know  whence 
came  this  inestimable  lesson.  I  can  remember  to  have 
heard  it  laughed  at  as  utterly  absurd. 

Before  leaving  the  subject  I  should  like  to  say  a 
few  words  as  to  the  more  recent  claims  made  by  Drs. 
Stevens  and  Ranney.  Men  who  run  into  extremes  are 
often  those  who  in  the  end  teach  proportioned  wisdom 
to  such  as  know  wisely  to  profit  by  the  excesses  of 
others.  This  is  going  to  be  the  case  in  regard  to  the 
extreme  views  enunciated  by  these  two  gentlemen. 
There  is  in   them  an   element   of   occasionally  useful 

1  The  literature  before  this  must  have  beeu  meagre  indeed.    See  American 
Medical  Library  Catalogue. 


REFLEX  OCULAR  NEUROSES.  227 

truth.  Where  they  appear  to  me  to  have  most  dis- 
tinctly failed  I  have  endeavored  to  point  out  to  the 
best  of  my  ability. 

At  my  clinic  for  two  years  or  more  Dr.  G.  E.  de 
Schweinitz  examined  with  the  utmost  care  the  eyes  of 
all  of  the  numerous  choreic  children  who  appeared  at 
the  Infirmary  for  Nervous  Diseases.  The  cases  ex- 
tended to  one  hundred,  and  although  many  of  them 
have  been  given  the  most  careful  attention,  I  do  not 
think  that  any  notable  good  in  the  \vay  of  cure  of 
chorea  was  obtained  by  correction  of  refractive  or  other 
errors.  In  the  disorder  I  first  described  as  ^'  habit- 
chorea'^  glasses  have  now  and  then  been  found  to  be 
useful,  but  not  often;  nor  should  we  expect  to  find 
anything  else  in  regard  to  chorea  proper.  It  is  largely 
a  disorder  of  seasons,  in  the  first  place  ;  and,  secondly,  it 
is  a  disease  easy  enough  to  treat.  The  great  mass  of 
cases  get  well  without  much  difficulty;  in  a  large 
number  of  instances  the  disease  is  self-limited,  and 
prospers,  even  if  let  alone ;  nor  has  it  the  gravity  which 
one  would  be  led  to  expect  from  reading  Dr.  Stevens's 
early  paper.  Dr.  de  Schweinitz  will,  I  am  sure,  en- 
tirely agree  with  the  conclusions  I  have  reached  as  being 
his  opinion  and  mine,  to  the  effect  that  we  have  gotten 
no  good  by  correcting  the  eyes  in  cases  of  chorea.  I 
came  to  this  matter  with  a  perfectly  free  and  unbiased 
mind,  but  this  was  the  end.  Choreal  children  with 
ocular  defects  got  well  under  arsenic  alone  quite  as  soon 
as  others  who  had  no  like  disorder  of  vision;  or  the 
choreas  got  well,  and  the  hypermetropia  remained  un- 
altered and  uncorrected. 

And  now  as  to  epileptics  I  have  met  with  no  better 
fortune.     As  regards  this,  I  have  read  with  care  the 


228  ^ER  VO  US  DISEASES. 

conclusions  of  Stevens  and  Eanney,  and  wished  I  could 
have  seen  some  of  the  epileptic  persons  whom  they  so 
successfully  treated.  Those  who  have  seen  much  of 
epilepsy  know  that  in  some  respects  it  is  a  very  curious 
disease.  If  we  take  an  obstinate  epileptic  case  and  put 
it  suddenly  under  new  conditions,  in  a  new  place,  with 
altered  diet  and  different  surroundings,  we  occasionally 
find  marked  changes  for  the  better,  which  are  usually 
temporary.  This  is  frequently  the  case  at  the  Infirmary. 
When  an  habitual  epileptic  is  admitted  for  the  purpose 
of  being  watched,  in  order  to  determine  the  quality  of 
the  spasm,  weeks  and  even  months  may  pass  without 
the  patient  having  an  attack,  Avheu  before  this  they 
occurred  every  day;  and  this,  too,  despite  the  discon- 
tinuance of  all  drugs.  I  know  of  cases  of  men  who  had 
such  attacks  before  entering  the  army,  and  who  under 
the  new  surroundings  w^ere  entirely  freed  from  them. 
These  are  the  things  which  make  neurologists  careful 
in  concluding  for  the  value  of  a  new  agent  in  this  sad 
malady  until  the  cure  has  lasted  a  long  while,  and  been 
observed  with  care.  Still,  there  are  cases  found  in 
Ranney's  last  contribution  (Eye  Treatment  of  Epi- 
leptics. New  York  Medical  Journal,  January  13,  20, 
and  27,  1894)  which  seem  to  have  ended  in  cures.  I 
can  only  say  that  we  have  failed  to  obtain  like  results  in 
our  own  attempts  to  cure  epilepsy  by  the  correction  of 
very  obvious  refractive  errors  or  by  cutting  tendons.  I 
neither  believe  nor  disbelieve.  When  I  can  see  two  or 
three  cases  of  cure  of  undoubted  epilepsy  by  tendon- 
clipping  I  shall  want  to  recommence.  So  far  I  have 
had  only  disappointment,  and  others  here  who  began 
to  cut  tendons  with  enthusiastic  hope  have,  like  me, 
got  no  good  for  their  patients  out  of  an  industriously 


REFLEX  OCULAR  NEUROSES.  229 

acquired  experience  in  this  direction.  I  shall  be  but 
too  happy  to  drop  the  dubious  mood  in  which  I  am  as 
to  this  whole  matter. 

I  believe,  as  regards  tenotomy  versus  prisms,  that  these 
surgeons  have  taught  us  a  lesson  which  we  may  with 
moderation  usefully  employ.  I  have  called  your  atten- 
tion to  the  matter  because  I  am  well  assured  that  if,  as 
to  tendon-cutting,  the  gentlemen  whom  I  have  so  frankly 
criticised  have  gone  too  far,  you,  I  think,  have  not  gone 
far  enough. 

I  have  tried  as  to  this  whole  matter  to  be  fair  and 
courteous,  and  yet  to  set  the  history  right.  As  concerns 
too  positive  views  of  treatment,  time  alone  will  entirely 
settle  these. 

And  now  a  word  or  two  as  to  your  own  relations  to 
the  disorders  in  which  we  see  ocular  troubles,  or  as  to 
those  in  which  these  are  the  cause  of  symptoms. 

I  trust  the  day  has  gone  when  you  will  put  on  prisms, 
or  cut  the  tendons  of  ataxic  cases  without  perceiving 
the  spinal  source  of  the  defects;  but  a  more  lasting  evil 
arises  out  of  the  fact  that  sometimes  you  do  not  compre- 
hend the  fact  I  have  long  tried  to  teach,  that  eye-strains 
lasting  through  the  years  of  development  may  make 
permanent  headaches  which  no  glass  will  do  more  than 
partially  relieve. 

Again,  you  often  see  people  who  owe  to  ill  health  a 
suddenly  intensified  capacity  to  feel  an  eye-strain.  You 
glass  them  and  expect  too  much.  Neither  you  nor  any 
specialist  can,  or  should,  escape  from  a  sense  of  larger 
responsibility ;  and  if  you  cannot  hold  your  patient 
when  you  have  corrected  the  eyes,  it  is  imperative  that 
he  learn  from  you  the  fact  that  he  needs  more  than 
merely  the  best  correction  of  the  eyes.     A  careful  study 

20 


230  NERVOUS  DISEASES. 

would  ofteu  tell  you  that  a  man  may  have  two  or  three 
forms  of  headache,  and  that  it  were  well  to  understand 
that  while  your  glasses  may  cure  an  occipital  ache,  for 
instance,  he  may  still  continue  to  have  neuralgic  hemi- 
cranial  pain,  or  an  occasional  attack  of  gouty  headache. 
I  suspect  that  our  own  oculists  are  far  in  advance  of 
the  English  and  most  Continental  surgeons  in  the  care 
which  with  they  correct  defects  in  refraction,  I  fancy 
that  they  sometimes  fail  to  get  the  best  possible  results 
because  of  difficulties  due,  it  may  be,  to  personal  pecu- 
liarities in  patients,  or  sometimes  to  the  belief  that  slight 
muscular  defects  may  be  let  alone  when  the  refraction 
has  been  accurately  corrected. 


CHAPTER   XIV. 

WRONG   REFERENCE   OF   SENSATIONS   OF   PAIN. 

It  occasionally  happens  that  in  the  large  clinical 
material  seen  at  the  hospital  we  meet  with  cases  that 
are  hardly  capable  of  nosological  classification,  and  yet 
are  not  without  their  lessons.  Here,  as  an  example,  is 
a  case  so  nnusaal  that  I  have  rarely  seen  one  like  it  or 
even  analogous  to  it.      It  is  a  very  simple  story  : 

Case  LXIII. — T.  M.  was  sent  to  my  clinic  at  the  In- 
firmary for  Nervous  Diseases  by  Dr.  J.  H.  McKee,  on  De- 
cember 7,  1894.  She  was  sixty-two  years  of  age,  born  in 
Pennsylvania,  and  married.  Her  mother  died  at  the  age 
of  ninety-five,  and  her  father  at  seventy-three  from  "  can- 
cer." Two  sisters  and  three  brothers  are  well.  One  sister 
died  of"  tuberculosis  "  and  one  brother  of  "  spotted  fever." 
The  woman  has  borne  three  sons ;  two  are  well,  and  one  is 
asthmatic.  She  takes  two  cups  of  strong  tea  and  two  of 
strong  coffee  daily,  and  beer  moderately.  The  menopause 
occurred  between  forty  and  forty-five  years  of  age.  She 
has  had  pneumonia  twice,  once  at  fifty-two  and  again  at 
fifty-seven  years  of  age. 

On  November  25,  1894,  thirteen  days  ago,  while  black- 
ing a  stove,  she  let  a  heavy  stove-plate  fall  on  the  right 
foot,  striking  the  toes.  The  great  toe  and  the  adjacent  one 
were  injured,  and  were  discolored  from  the  bruising.  A 
line  of  blackish  discoloration  is  still  present  under  the  nail 
of  the  second  toe.  But  there  is  no  swelling  or  redness, 
though  some  pain  still  persists. 

Immediately  on  the  reception  of  the  injury  she  felt  acute 


232  ^ER  VO  US  DISEASES. 

pain  on  the  autero-internal  aspect  of  the  left  leg  (the  unin- 
jured side)  at  the  junction  of  the  upper  and  middle  thirds. 
This  pain  extended  downward  into  the  foot  and  upward 
into  the  thigh.  It  was  of  a  burning  character,  fairly  con- 
stant, but  worse  at  night.  At  present  the  appetite  is  good 
and  improving,  the  tongue  is  clean,  there  is  no  vomiting, 
but  the  woman  has  an  occasional  headache  attended  with 
nausea. 

The  heart's  action  is  rhythmic,  the  sounds  distinct.  The 
vascular  tension  is  moderately  increased.  The  radial  and 
temporal  arteries  are  tortuous  and  resistant.  There  is  slight 
vertigo,  no  dyspnoea,  and  no  swelling  of  the  feet.  There 
is  an  increased  frequency  of  micturition,  both  nocturnal 
and  diurnal.  The  urine  contains  no  albumin  or  sugar  and 
has  a  specific  gravity  of  1022. 

The  woman  has  lost  flesh  in  the  last  two  weeks,  because, 
as  she  states,  of  the  severity  of  the  pain.  She  has  not  had 
chills,  fever,  or  sweats.  She  sleeps  poorly,  and  worse  since 
the  accident.  Memory  is  good  and  hearing  is  fairly  good  ; 
but  the  eyesight  is  poor,  although  improved  by  glasses. 
The  station  is  a  little  unsteady.  The  knee-jerks  are  active, 
and  sensation  is  apparently  normal.  There  is  no  history 
of  traumatism  of  the  left  leg.  The  left  tibia  is  particularly 
tender  in  the  middle  third,  on  the  inner  and  outer  margins. 
The  left  leg  is  also  more  florid  and  the  temperature  slightly 
higher.  There  is  no  inflammatory  or  other  deposit  present. 
An  electric  examination  of  the  tibial  group  of  muscles 
shows  a  slight  quantitative  decrease  to  the  faradic  current. 
There  is  no  galv^anic  change. 

On  December  21,  1894,  the  woman  was  better,  under 
the  daily  use  of  galvanism.  On  January  8,  1895,  constant 
gain  was  reported. 

I  have  personally  gone  over  this  case  with  extreme 
care,  and  see  no  cause  to  disbelieve  the  statement  made 
by  the  j)atient.     She  declares  that,  having  had  a  heavy 


MISREFEBENCE  OF  SENSATIONS  OF  PAIN     233 

weight  fall  on  the  right  foot,  there  was  at  once  a  pain 
in  the  left  shin  so  sharp  as  to  distract  her  attention 
from  the  quite  severe  injury  received  by  the  opposite 
member.  Also  she  declares  that  the  referred  pain  has 
now,  for  three  weeks,  survived  that  of  the  part  hurt. 

This  case,  unusual  as  it  is,  seems  not  to  be  unique. 
In  fact,  I  came  yesterday,  in  Sharkey  on  Epilepsy,  upon 
a  case  in  which  the  pain  caused  by  an  injection  for  gon- 
orrhoea was  felt  as  an  acute  pain  on  top  of  the  head.  T 
myself  recall  two  of  which  I  have  personal  knowledge. 
One  was  that  of  a  man  who,  having  a  felon  on  the  right 
thumb,  had,  until  it  was  relieved,  severe  pain  in  the 
opposite  thumb.  The  reference  was  to  both  thumbs, 
and  not  from  a  foot  to  a  non-symmetric  part  of  the 
opposite  limb.  In  another  case,  in  which  an  omnibus- 
window  was  let  fall  on  a  finger  in  which  was  a  felon, 
there  was  with  the  pain  of  the  finger  a  lasting  and 
very  violent  pain  in  the  face  and  neck  of  the  other 
side. 

I  have  also  some  remembrance  of  having  many  times 
heard  during  the  great  Civil  War  from  men  shot  state- 
ments as  to  their  having  felt  the  wound  as  pain  in  some 
remote  part  of  the  body.  In  the  notes  of  that  time 
made  by  Morehouse,  W.  W.  Keen,  or  by  me,  I  find, 
in  fact,  interesting  examples  of  the  kind  of  referred  pain 
seen  in  this  woman. 

One  was  the  case  of  Captain  now  Admiral  Stembel, 
who,  being  shot  through  the  right  side  of  the  neck,  had 
with  reflex  paralysis  of  the  left  arm  also  pain  in  that 
unwounded  member.     Other  instances  are  as  follows: 

Case  II.  of  Circular  No.  YL,  1864.  A  shell-wound 
of  one  leg  (right)  at  once  gave  rise  to  burning  pain  in 
both  feet  and  in  the  right  arm  and  right  pectoral  region. 

20- 


234  NER  VO  US  DISEASES. 

Case  VI.  A  Avoiind  of  the  testicle  was  referred  to 
the  back,  where  alone  was  any  pain  felt. 

Case  V.  A  shell-wound  of  the  outer  side  of  the  left 
thigh  with  immediate  reference  of  pain  to  the  same  area 
on  both  thighs.  The  man  thought,  indeed,  that  he 
was  shot  through  both  thighs.  Other  of  onr  cases  ex- 
hibited similar  phenomena  of  cross  or  symmetric  or 
non-symmetric  reference  of  the  pain  of  a  wound. 

Case  YI.,  in  Hutchinson's  series,  p.  313,  is  one  of 
injury  of  the  median  and  ulnar  nerves  which  gave  rise 
to  pain  in  the  opposite  hand.  Pirogoff  has  a  report  of 
the  same  form  of  cross-reference  from  a  wound.  Such 
false  reports  as  to  the  seat  of  pain-cause  are  not  rare  as 
regards  the  branches  of  a  single  nerve.  A  familiar 
example  is  seen  or  felt  in  the  widely  referred  pain  from 
an  exposed  dental  nerve. 

Our  present  case  does  not  stand  alone.  Neverthe- 
less, instances  of  unsymmetrical  cross-reference  are 
rare  enouo^h  to  make  it  worth  while  to  call  them  to 
your  attention. 

One  of  my  older  friends,  now  dead,  a  naturalist  of 
great  distinction,  had  on  one  leg  a  small  mole.  If  this 
was  roughly  rubbed  or  pinched,  he  had  at  once  a  sharp 
pain  in  his  chin.  More  interesting  are  the  cases  in 
which  after  a  nerve-section,  or  late  in  a  neuritis,  there 
is  a  reference  centrad  of  touch  at  some  lower  point.  I 
long  ago  described  this  class  of  facts,  and  not  very 
successfully  commented  upon  their  cause.  In  his 
book  on  Remote  Consequences  of  Nerve  Injuries  John 
K.  Mitchell  gives  many  illustrations  of  this  form  of 
referred  touch-sense.  He  has  also  still  more  curious 
cases  of  sensations  referred  pcripherad  or  to  a  remote 


MISREFEBENCE  OF  SENSATIONS  OF  PAIN.     235 

The  unusualness  of  the  present  case  lies  in  the  con- 
tinuance of  pain  in  the  remote  region  long  after  the 
seat  of  the  originating  cause  had  ceased  to  be  painful. 

I  do  not  think  that  we  are  as  yet  prepared  to  reason 
upon  some  of  these  symptoms.  I  refer  the  curious  to 
the  book  I  have  last  mentioned.  One  can,  in  a  meas- 
ure, comprehend  that  a  violent  stimulus  to  a  sensory 
nerve  may  be  switched  off  on  to  other  nerve-tracts  or 
centres,  as  if  it  were  the  escape  of  an  over-charge;  but, 
even  if  we  hazard  such  an  hypothesis,  it  is  still  difficult 
to  explain  the  persistency  of  certain  of  these  transferred 
impressions,  for  it  is  a  law  of  the  receiving  centres  for 
painfid  impressions  that  when  the  cause  of  the  pain 
ceases  to  be  active  the  feeling  of  being  hurt  ends.  But 
in  some  of  these  examples  of  false  reference  of  pain 
there  must  have  been  made  in  a  centre  some  more  or  less 
permanent  change  that  continuously  represents  the  effect 
to  which  any  pain-making  agency  usually  gives  rise. 


CHAPTER   XV. 

PSEUDOCYESIS :   SPURIOUS   PEEGXAXCY. 

I  HAD  hoped  to  show  you  to-clay  a  case  which  is  of 
unusual  interest  and  of  the  utmost  rarity.  The  patient 
will,  I  think,  come  hither  sooner  or  later,  because  she 
is  convinced  I  am  wrong  as  to  her  state,  and  because 
she  believes  that  Professor  Hirst,  whom  I  shall  ask  to 
see  her,  will  agree  with  her  and  disagree  with  me. 
Moreover,  she  is  hysterical  and  inclined  to  exhibit  her- 
self. I  shall  not  wait  for  her  return,  as  it  may  never 
happen,  but  take  her  case  as  a  text  or  an  excuse  for 
dwelling  on  a  subject  of  interest  to  both  the  obstetrician 
and  the  neurologist. 

I  find  it  somewhat  hard  to  fit  her  case  and  others 
like  it  with  a  label.  If  I  call  it  simulation  of  preg- 
nancy, that  would  be  near  to  a  satisfactory  name;  it 
would  not  fully  satisfy  me.  As  usual,  I  should  have 
to  qualify  and  explain  it.  Perhaps  it  were  well  to 
leave  the  matter  until  I  have  stated  some  illustrative 
examples.  Before  doing  so  I  shall  give  an  outline  of 
the  condition  for  which  I  claim  your  attention. 

A  woman,  young,  or  it  may  be  at  the  climacteric, 
eagerly  desires  a  child,  or  is  horribly  afraid  of  becom- 
ing pregnant.  The  menses  become  slight  in  amount, 
irregular,  and  at  last  cease  or  not.  Meanwhile  the  abdo- 
men and  breasts  enlarge  owing  to  rapid  taking  on  of 
fat,  and  this  is  less  visible  elsewhere.  There  comes 
with  this  excess  of  fat  the  most  profound  conviction  of 


SPURTO US  PREGNANCY.  237 

the  fact  of  pregnancy.  By  and  by  the  child  is  felt,  the 
physician  takes  it  for  granted,  and  this  goes  on  until 
the  great  diagnostician,  Time,  corrects  the  delusion. 
Then  the  fat  disappears  with  remarkable  speed  and  the 
reign  of  this  singular  simulation  is  at  an  end.  When 
I  describe  one  or  two  of  these  cases  you  will,  I  fancy, 
agree  with  me  that  the  subject  is  worth  discussing. 

Perhaps  the  cases  may  be  more  frequent  than  I  think 
they  are.  As  a  consultant  I  might  rarely  hear  of  them. 
The  general  physician  and  the  obstetrician  are  more 
liable  to  encounter  them,  and  yet  they  must  be  uncom- 
mon. Some  years  ago  I  asked  Dr.  Duer  if  he  recalled 
the  two  or  three  cases  of  this  nature  sent  to  him  by  me. 
He  said  yes,  and  that  he  had  also  met  with  one  or  two 
others.  Shortly  after  this  I  was  consulted  by  a  lady 
in  regard  to  a  woman  of  thirty  years  of  age,  a  nurse  in 
whom  she  was  interested.  This  person  had  been  mar- 
ried some  three  years  to  a  very  old  man  possessed  of  a 
considerable  estate.  He  died,  leaving  his  wife  her  legal 
share  and  the  rest  to  distant  cousins,  unless  the  wife 
had  a  child.  For  two  months  before  he  died  the  woman, 
who  was  very  anaemic,  ceased  to  menstruate.  She  be- 
came sure  that  she  was  pregnant,  and  thereuxwn  took 
on  flesh  at  a  rate  and  in  a  way  which  seemed  to  justify 
her  belief.  Her  breasts  and  abdomen  were  the  chief 
seats  of  this  overgrowth.  The  menses  did  not  return, 
her  pallor  increased;  the  child  was  felt,  and  every  prep- 
aration made  for  delivery.  At  the  eighth  month  a 
physician  made  an  examination  and  assured  her  of  the 
absence  of  pregnancy.  A  second  medical  opinion  con- 
firmed the  first,  and  the  tenth  month  found  her  of 
immense  size  and  still  positive  as  to  her  condition.  At 
the  twelfth  month  her  menstrual  flow  returned,  and  she 


238  ^^ER  VO  US  DISEASES. 

became  sure  it  was  the  early  signal  of  labor.  When  it 
passed  over,  convinced  of  her  error,  she  at  once  dropped 
weight  at  the  rate  of  half  a  pound  a  day  despite  every 
effort  to  limit  the  rate  of  this  remarkable  loss.  At 
the  end  of  two  months  she  had  parted  with  fifty  pounds 
and  was  on  the  whole  less  anaemic.  At  this  stage  I 
was  consulted  by  letter,  as  the  woman  had  become  ex- 
ceedingly hysterical. 

Another  instance  I  saw  when  in  general  practice. 
A  lady  who  had  several  children  and  suffered  much  in 
her  pregnancies,  passed  five  years  without  becoming 
impregnated.  Then  she  missed  a  period,  and  had  as 
usual  vomiting.  She  made  some  wild  efforts  to  end 
her  supposed  pregnancy,  and,  failing,  accepted  her  fate. 
Meanwhile  she  vomited  up  to  the  eighth  month,  and 
ate  little.  Nevertheless  she  took  on  fat  so  as  to  make 
the  abdomen  and  breasts  immense  and  to  excite  un- 
usual attention. 

Xo  physician  examined  her  until  the  supposed  labor 
began,  when,  of  course,  the  truth  came  out.  She  was 
})leased  not  to  have  another  child,  and  in  her  case,  as 
in  all  the  others  known  to  me,  the  fat  lessened  as  soon 
as  the  mind  was  satisfied  as  to  the  non-existence  of 
pregnancy.  As  I  now  recall  the  facts,  this  woman  was 
not  more  than  two  months  in  getting  rid  of  the  excess 
of  adipose  tissue. 

Dr.  Hirst  tells  me  he  has  met  \\ith  cases  of  women 
taking  on  fat  with  cessation  of  the  menses  in  which 
there  was  also  a  steady  belief  in  the  existence  of  preg- 
nancy. He  has  not  so  followed  up  these  cases  as  to 
know  if  in  them  the  fat  fell  away  with  speed  when  once 
the  patient  was  assured  that  no  child  existed  within 
her.      ^ly  much  regretted  friend  Goodell's  death  de- 


SPURIOUS  PREGNANCY.  239 

prived  me  of  the  detailed  account  of  at  least  two 
examples  having  precisely  the  sequence  of  symptoms 
I  have  described. 

These  women  are  in  no  sense  of  unsound  niindj  nor 
is  their  illusion  to  be  classified  with  the  obstinate  belief 
as  to  pregnancy  held  by  some  of  the  insane.  These 
latter  persons  may  be  virgins  or  not.  Sometimes  the 
idea  has  arisen  in  connection  with  uterine  symptoms, 
or  else  is  the  outcome  of  some  exposure  to  the  creation 
of  pregnancy  and  alarm  at  a  possible  but  non-existent 
pregnancy.  Many  of  these  people  hold  to  the  notion 
for  years.  Dr.  Hirst  recalls  to  me  the  story  of  Dupuy- 
tren,  who,  when  consulted  for  such  a  case  of  eighteen 
years'  duration  (the  patient  was  of  the  belief  that  she 
was  going  to  have  a  son),  advised  the  woman  to  swallow 
a  private  tutor.  It  is  said  to  have  cured  the  case, 
which  I  much  doubt.  I  knew  of  one  instance  in 
which  a  physician  etherized  such  a  case,  and  assured 
the  woman  he  had  taken  away  a  dead  child.  This 
answered  for  a  week,  and  then  she  confided  to  him  her 
regret  that  he  had  not  taken  away  the  other,  as  now  she 
knew  they  were  twins. 

The  delusion  of  pregnancy  in  the  insane  is  neither 
created  nor  kept  up  of  need  by  excess  of  flesh  or  failure 
of  menstruation.  No  such  food  for  fancy  is  needed. 
These  cases  defy  the  contradictions  of  time  and  the 
popular  knowledge  of  physiology.  On  the  other  hand, 
the  illusion  of  the  patients  I  describe  is  inevitably  de- 
stroyed by  time  and  adverse  circumstance. 

I  can  find  no  mention  anywhere  in  literature  of  cases 
precisely  like  those  I  have  described.  Perhaps  I  may 
have  overlooked  them  or  they  might  be  found  on  more 
careful  search.    Yet,  after  inquiry  of  men  with  the  large 


240  ^^ER  VO  us  DISEASES. 

experience  of  Goodell,  Diier,  and  Hirst,  I  am  forced  to 
belie v^e  them  exceptionally  rare. 

A  woman  is  emotionally  eager  to  have  or  not  to  have 
a  child;  one  with  the  unsatisfied  craving  for  mother- 
hood, or  one  who  has  been  fearfully  tormented  in  her 
pregnancies — these,  I  think,  are  the  classes  of  women 
liable  to  this  complex  group  of  symptoms.  More  rarely 
it  is  a  woman  long  childless,  who  somewhat  early  and 
suddenly  ceases  to  flow,  and,  as  is  not  rare  at  the  climac- 
teric, puts  on  flesh  very  rapidly.  The  illusion  of  preg- 
nancy is  ia  such  females  a  flattering  one. 

The  other  cases  are  the  more  interesting.  The  woman 
has  naturally  and  too  constantly  dwelt  with  disappointed 
hope  or  abiding  fear  on  the  loss  or  delay  of  the  periodic 
bleeding.  Then  she  becomes  more  gladly  sure  or  more 
alarmed,  as  the  case  may  be,  as  she  gains  flesh  and 
especially  abdominal  fat.  Is  this  gain  in  flesh  an  acci- 
dent of  nutrition  which  combines,  with  lessened  or 
absent  menstruation,  to  give  and  sustain  her  growing 
illusion  as  to  pregnancy  ?  Women,  as  I  long  ago 
remarked  in  my  book  on  Rest-treatment,  are  easier  to 
fatten  than  men;  also  in  them  gain  or  loss  of  adipose 
tissue  is  more  common  than  in  the  other  sex,  and  less 
significant  as  to  health  or  of  pathological  disaster.  The 
point  as  to  which  I  remain  in  doubt  is  as  to  whether 
belief  in  the  presence  of  the  pregnant  condition  in  any 
way  influences  the  really  singular  gain  in  fat  seen  in 
certain  of  these  cases.  Whether  it  is,  as  I  said,  coinci- 
dent and  assistant  of  belief,  or  whether  it  follows  that 
mental  state,  I  do  not  know.  Some  women  thus  de- 
luded are,  Avhen  once  assured  of  pregnancy,  likely  to 
be  careful  to  exercise  less  than  usual,  and  acquire,  like 
some  pregnant  women,  excessive  appetites.      Also  it  is 


SPURIOUS  PREGNANCY.  241 

quite  sure  that  once  they  are  convinced  of  their  dekision 
they  lose  flesh  very  speedily,  and  this,  too,  may  be  in 
a  measure  due  to  a  return  to  normal  habits.  Still  there 
remains  for  us  the  unsolved  problem  of  how  much  the 
mind  has  to  do  with  the  gain  and  loss  of  weight.  The 
first  of  these  cases  I  ever  saw  was  brought  to  my  knowl- 
edge in  a  singular  way:  A  woman  had  given  birth  to 
two  female  children.  Some  years  passed,  and  her  desire 
for  a  boy  was  ungratified.  Then  she  missed  her  flow 
once,  and  had  thrice  after  this,  as  was  customary  with 
her  when  pregnant,  a  very  small  but  regular  loss. 
At  the  second  month  morning  vomiting  came  on,  and 
this  too  was  usual.  Meanwhile  she  grew  very  fat, 
and,  as  the  growth  was  largely  abdominal,  she  became 
easily  sure  of  her  condition.  She  was  not  my  patient, 
but  her  husband  consulted  me  as  to  his  own  morning 
sickness,  which  came  with  the  first  occurrence  of  this 
sign  in  his  wife,  as  had  been  the  case  twice  in  her 
former  pregnancies.  I  advised  him  to  leave  home, 
and  this  proved  effectual.  I  learned  later  that  the 
woman  continued  to  gain  flesh  and  be  sick  every 
morning  until  the  seventh  month.  Then  menstrua- 
tion returned,  an  examination  was  made,  and  when 
sure  that  there  was  no  possibility  of  her  being  pregnant 
she  began  to  lose  flesh,  and  within  a  few  months  re- 
gained her  usual  size. 

The  sympathetic  vomiting  of  the  husband  is  an  inter- 
esting subject  to  which  I  called  attention  some  years 
affo  in  mv  lectures  on  nervous  maladies. 


21 


CHAPTER    XVI. 

HYSTERICAL    CONTRACTURES. 

These  clinical  lessons  are,  in  a  measure,  the  offspring 
of  opportunity.  The  wards  have,  of  late,  given  us  cases 
of  contracture  that  have  been  so  interesting  and  so  sug- 
gestive as  to  tempt  me  to  call  attention  to  their  diag- 
nosis and  especially  to  their  treatment.  The  subject  is 
in  no  sense  exhausted. 

We  do  not  know  what  hysteria  is.  So  far,  death  has 
destroyed  in  all  cases  what  evidence  life  might  have 
offered  as  to  its  existence  as  an  obvious  thing  capable 
of  visual  demonstration;  and  still  we  are  apt,  sometimes 
with  too  much  confidence,  to  refer  back  its  manifesta- 
tions to  this  or  that  centre.  Thus,  it  has  been  taken 
for  granted  that  hysterical  contracture  is  due  to  disorder 
somewhere  present  in  such  columns  of  the  cord  as  are 
usually  diseased  in  cases  of  spastic  paralysis.  The  chief 
basis  on  which  this  opinion  rests  is  this:  Cases  of  long- 
continuing  hysterical  contracture  have  been  seen  to  end 
in  sclerotic  alterations  of  the  lateral  columns  of  the 
spinal  cord.  The  inference  is  that  the  precedent  func- 
tional states  were  also  due  to  the  less  visible  hysterical 
conditions  of  these  columns.^  Moreover,  it  has  been 
taken  for  granted  that  the  state  of  contracture  is  anal- 
ogous to  the  condition  we  find  present  in  muscles  ren- 
dered over-responsive  by  lateral  sclerosis. 

1  Charcot:  Soc.  med.  des  HOpitaux,  vol.  ii.,  2d  series,  p.  24, 


HYSTERICAL  CONTRACTURES.  243 

I  am  not  at  all  secure  that  these  inferences  are  safe, 
or  even  that  contracture  is  of  a  certainty  due  to  spinal 
centres  at  all.  It  is  quite  possibly  purely  local  and 
muscular  as  to  origin;  and,  indeed,  there  are  reasons 
why  it  is  extremely  difficidt  to  consider  it  as  of  spinal 
birth,  or  in  any  way  analogous  to  the  state  of  excita- 
bility seen  in  disease  of  the  lateral  columns. 

The  history  of  contracture  is  briefly  this  :  Under  an 
influence,  such  as  emotion,  or  from  causes  unknown, 
but  usually  in  a  frankly  hysterical  case,  a  group  or 
groups  of  muscles  contract  abruptly  or  by  degrees. 
These  spasms  may  involve  flexors  or  extensors,  or  both 
at  once.  Tliey  may  affect  one  muscle  or  almost  every 
group  in  all  four  extremities,  and  also  the  truncal  mus- 
cles. The  condition  thus  developed  may  last  for  days 
or  years.  The  muscles  concerned  are  not  over-respon- 
sive to  blows  or  to  electricity.  The  skin-reflexes  are 
normal  or  nearly  so;  the  knee-jerk  and  ankle-jerk  may 
not  be  in  excess.  Clonus  is  absent,  or,  if  present,  inde- 
cisive or  brief,  as  we  see  it  in  hysteria  or  in  over-excit- 
able, weak  people.  The  prolonged  muscular  action 
seems  not  to  raise  the  local  temperature.  If  you  deeply 
anaesthetize  the  patient,  the  muscles  relax,  but  not 
always  nor  fully  except  early  in  the  case.  An  Esmarch 
bandage  commonly  gives  rise  to  complete  relaxation. 
In  sleep  some  early  cases  relax;  others  do  not.  Very 
gentle  effort  in  sleep  to  alter  the  angle  of  the  limb  may 
succeed,  but  the  least  abruptness  of  pull  calls  out  a 
spastic  response.  Otherwise  the  spasm  is  usually  con- 
stant, and  efforts  to  overcome  it  forcibly  give  great  pain. 
Very  often  there  is  loss  of  normal  power  in  such  mus- 
cles as  are,  and  even  in  such  muscles  of  the  affected 
limb  as  are  not,  in  a  state  of  spasm.      Usually  there  is 


244  NEB  VO  US  DISEA  SES. 

profound  anaesthesia,  confined  to  the  disordered  limbs 
or  involving  half  the  body. 

I  have  said  that  the  spasm  is  chronic,  and  this  is  the 
rule;  but  I  have  seen  cases  in  which  it  came  and  weut, 
or  was  seen  only  on  alternate  days.  Quite  often  the 
flexors  or  extensors  alone  are  contractured,  but  in  the 
sad  examples  of  general  chronic  spasm  both  sets  of 
muscles  are  apt  to  suffer. 

A  contracture  may  last  for  years,  and  go  as  abruptly 
as  it  came — or,  it  is  so  said.  I  have  never  seen  this 
happen,  but  I  cannot  doubt  the  positive  statements 
made  by  others. 

Under  early  reasonable  treatment  these  spasms,  if 
locally  limited  to  single  groups  of  muscles,  are  apt  to 
get  well.  My  own  efforts  to  cure  them  with  discs  of 
metal,  magnets,  or  by  hypnotic  suggestion  have  left  me 
with  mere  histories  of  defeat.  And  yet  under  other 
treatments  I  often  see  these  cases  get  well  early.  But 
this  is  not  true  of  the  more  extensive  contractures;  in 
fact,  the  more  extensive  the  region  affected  the  more 
difficult  the  early  treatment. 

Now  let  us  look  at  the  graver  form,  that  of  multiple 
contracture.  A  patient  far  gone  in  the  sad  drama  of 
hysteria  has  slowly,  or  abruptly,  or  after  the  part  has 
been  paralyzed  and  become  insensible,  a  contracture  of 
one  limb,  which  gets  worse.  In  a  week  or  two  the  other 
limb  suffers.  Still  later  the  remaining  extremities  be- 
come drawn  up,  and  even  the  face,  neck,  belly,  and 
thorax  are  involved.  There  are  paralysis,  surface- 
anaesthesia,  and  intense  spasm.  Pain  is  rare,  unless 
called  out  by  pressure  or  motion.  Usually  all  the  mus- 
cles suffer,  but  the  attitude  is  commonly  one  of  extreme 
flexion,   either  because  of   the  greater  power  of   the 


HYSTERICAL  CONTRACTURES.  245 

flexors,  or  that  they  are  the  more  excited.  In  some 
cases  the  limbs  are  in  extreme  spastic  extension,  or 
this  is  the  case  as  to  the  legs,  and  not  as  to  hands  and 
arms.  Very  early  in  these  cases  the  muscle-muscle- 
reflexes^  are  mechanically  abolished  or  are  pathologi- 
cally interfered  with;  and  later  all  reflexes  may  disap- 
pear in  the  disordered  parts,  and  even  direct  response 
to  a  blow  on  the  mnscle  be  lost.  There  is  apt  to  be 
diminished  quantitative  muscular  response  to  faradic 
currents,  and  after  years  even  galvanic  responses  may 
be  lessened.  The  anaesthesia  is  of  the  surface,  and  is 
finally  profound. 

Sleep  does  not  relax  these  cases  after  they  have  existed 
for  some  months.  Great  but  uniform  wasting  is  seen. 
The  muscles  harden.  About  the  joints  and  between 
the  tendons  a  similar  but  far  greater  leathern-like  har- 
dening is  found.  Ether  or  chloroform  no  longer  causes 
relaxation  ;  nor  does  an  Esmarch  bandage,  or  even 
section  of  the  tendons,  give  rise  to  relaxation  as  in  the 
local  contracture. 

This  is  a  different  symptom-group.  If  we  ask  our- 
selves. What  has  happened  ?  What  is  the  cause  ?  we  are 
at  once  face  to  face  with  a  grave  and  interesting  prob- 
lem. Without  a  history  v*^e  would  be  apt  enough  to 
consider  such  a  case  as  one  of  anterior  poliomyelitis.  It 
is  but  a  sketch  of  that  malady;  it  is  not  a  true  picture. 
But  suppose  this  patient  bedridden  for  a  score  of  years. 
I  have  seen  such  cases,  in  which  the  cold,  absolutely 
angesthetic  limbs  have  lost  all  reflexes,  and  in  which  the 
shrunken  muscles  refuse  to  move  under  any  form  of 
electric  current,  save  here  and  there  to  powerful  gal- 


By  these  are  meant  the  knee-jerks,  etc. 
21* 


246  NERVOUS  DISEASES. 

vauic  alternations.  The  picture  of  an  anterior  spinal 
malady  seems  then  to  be  fairly  complete. 

This  sad  condition  belono^s  only  to  the  multiple  con- 
tractures. It  is  never  found  in  the  single-limb  spasm, 
no  matter  how  lasting  that  may  be.  I  have  seen  con- 
tracture of  the  extensors  of  one  leg  endure  six  years  and 
show  no  sign  of  the  peculiar  permanent  hardening  which 
marks  the  second  stage  of  some  more  generalized  con- 
tractures. I  recall  one  case  in  which  for  niue  years  the 
left  gastrocuemial  group  remained  in  violent  contracture. 
Then  a  section  put  an  end  to  the  spasm.  To  my  sur- 
prise the  muscle  thus  released  from  tension  was  soft  and 
had  not  shrunk.  In  both  of  these  cases,  when  under 
ether,  the  relaxed  muscle  behaved  to  electricity  like  a 
normal  muscle. 

All  of  this  is  unlike  Avhat  happens  in  the  contractures 
affecting  two  or  more  extremities.  Here,  even  iu  the 
very  early  months,  the  muscles  may  begin  to  show  a 
brawn-like  hardness,  which  is  a  constant  condition  and 
not  to  be  altered  by  anaesthetics.  The  muscle,  at  first 
spasmodically  shortened,  becomes  organically  set  and 
stiffened.  There  is  still  and  always  more  or  less  spasm, 
or  at  least  this  may  be  the  case  for  years.  It  is  also 
possible  that  joint-lesions  due  to  long  disuse  and  to 
subluxations  may  have  finally  their  share  in  adding  to 
this  complex  symptom-group  the  element  of  reflex  mus- 
cular contractions. 

You  may  have  already  inferred  that  I  have  become 
quite  assured  that  there  are  two  forms  of  hysterical 
contracture:  one  apt  to  be  local  and  limited  and  not 
followed  by  organic  muscular  changes;  the  other  apt  to 
affect  two  or  more  limbs,  and  almost  every  muscle,  even 


HYSTERICAL  CONTRACTURES.  247 

of  the  trunk,  and  prone  to  result  in  the  muscular  and 
areolar  tissue-changes  already  described. 

I  think  it  curious  that  while  the  early  stage  of  gen- 
eral contracture  is  most  difficult  of  cure,  when  the  dis- 
ease has  caused  organic  changes  and  is  in  its  second 
stage  it  is  far  less  hard  to  deal  with.  Perhaps  this  may 
be  due  in  part  to  the  disappearance  of  active  hysteria. 
Indeed  it  is  often  true  that  in  certain  old  examples  of 
contracture  the  symptom,  contracture,  exists  no  longer, 
and  we  have  to  deal  only  with  the  mischief  of  organ- 
ically shortened  muscles,  altered  joints,  and  sclerematous 
changes  in  the  intermuscular  spaces.  The  hysteria  is 
lost  with  years;  the  spasm  lessens  or  ceases;  the  conse- 
quences and  additions  remain. 

I  have  said  enough  to  enable  you  to  separate  this 
peculiar  state  from  disease  of  the  lateral  or  from  that 
of  the  anterior  gray  columns  of  the  cord.  If,  however, 
any  other  test  be  needed,  it  is  to  be  found  in  the  ease 
and  speed  with  which  under  rubbing  and  faradic  elec- 
tricity these  wasted  muscles  recover  their  characteristic 
excitability.  AYith  this  return  such  reflex  actions  as 
had  been  mechanically  obliterated  again  become  vis- 
ible, but  the  skin-reflexes  remain  absent  until  the  anaes- 
thesia passes  away. 

Richet  divides  contractures  into  -painful  and  painless. 
I  never  saw  a  case  of  constantly  painful  contracture  in 
America.  Some  of  these  cases,  however,  become  pain- 
ful for  a  reason  not  always  present  and  Avhich  only  of 
late  has  become  clear  to  me.  In  general  the  painless 
contracture  may  be  made  painful  by  quite  moderate 
efforts  to  overcome  the  contraction ;  and  in  old  cases, 
such  as  I  shall  describe,  the  pain  on  movement  is  in  the 


248  NER  VO  US  DISEASES. 

joints  and  not  in  the  muscles.  In  advanced  cases  of 
extreme  contracture  of  the  legs  you  meet  now  and  then 
with  examples  of  agonizing  pain,  apt  to  be  referred  to 
the  feet  and  never  seen  in  the  arm.  I  had  long  con- 
sidered this  symptom  as  of  spinal  parentage.  Some 
years  ago,  however,  I  was  led  in  a  seemingly  hopeless 
case  to  suspect  that  the  very  great  suffering  present 
mio^ht  be  due  to  the  stretchino^  of  the  sciatic  nerves  at 
the  notch  and  to  a  possible  localized  irritation  or  even 
neuritis.  A  number  of  tendons  were  cut  and  partial 
extension  effected.  Immediate  relief  followed  and  the 
pain  continuously  lessened  as  extension  by  instruments 
became  more  complete.  Encouraged  by  this  unlooked- 
for  success,  the  case  was  attacked  with  larger  hope,  and 
in  the  end  I  had  the  pleasure  of  seeing  a  young  and 
intelligent  woman  restored  to  a  life  of  healthy  useful- 
ness. I  happen  to-day  to  have  seen  this  woman;  a 
strong,  well-nourished,  and  apparently  vigorous  person. 
Looking  back  to  the  gnarled,  blind,  speechless  patient 
of  years  ago,  it  seems  a  quite  incredible  rescue.  Noth- 
ing except  the  rapid  cure  in  this  case  shook  my  belief 
that  very  material  organic  change  in  the  cord  had  taken 
place.  So  far  as  my  own  knowledge  goes,  post-hys- 
terical sclerosis  of  the  cord  occurs  only  in  generalized 
contracture,  after  ten  or  twenty  years  of  life  in  bed. 
In  one  such  case  I  saw,  after  death,  a  moderate,  irregu- 
larly scattered  sclerosis  of  the  anterior  columns  and 
gray  matter. 

With  such  a  symptom-group  before  us  as  I  have 
already  described  as  existing  in  old  cases  of  multiple 
contracture,  it  is  almost  impossible  for  the  inexperi- 
enced to  disbelieve  the  presence  of  more  or  less  organic 
fascial  change  in  the  cord.     So  difficult  is  it,  indeed. 


HYSTERICAL  CONTRACTURES.  249 

that  I  have  often  asked  myself,  if  it  may  not  be  that 
organic  lesions  in  hysterical  people  have  a  less  serious 
hold  on  the  tissues  than  such  as  come  in  the  ordinary 
way,  without  precedent  hysteria.  Either  we  must  accept 
some  such  conclusion,  or  else  believe  that  the  group  of 
symptoms  delineated  may  occur  without  having  for  their 
parents  organic  material  lesions  of  central  nerve-cell 
and  fibre.  I  trust  I  make  clear  how  difficult  is  this 
problem. 

It  is  especially  interesting  to  me  just  now,  because  I 
have  in  my  care  a  young  woman  whose  case  is  very  like 
that  I  just  now  mentioned  as  fortunate.  As  our  first 
illustration  of  contracture  and  of  many  of  the  most  re- 
markable incidents  of  hysteria,  I  shall  have  read  to  you 
at  length  this  strange  story  of  disease.  It  is  rare  that 
a  record  has  been  kept  with  the  care  given  to  this  one: 

Case  LXIV. — E.  M.  H,,  of  Arkansas,  is  a  girl  fifteen 
years  of  age,  whose  parents  are  in  good  health,  and  who 
has  three  brothers  and  sisters  alive  and  well.  The  mother 
has  had  two  miscarriages  ;  one  child  was  born  prematurely, 
and  one  died  of  hydrocephalus  at  six  months.  A  materual 
aunt  was  insane. 

The  patient  was  born  at  term,  without  difficulty  and 
without  instruments,  and  proved  to  be  a  healthy  and  well- 
formed  baby.  She  was  breast-fed  for  six  months ;  never 
had  convulsions,  and,  although  she  had  scarlet  fever,  her 
childhood  was  fairly  healthy. 

She  learned  to  walk  and  talk  early  and  well;  was,  in 
fact,  a  bright,  intellectual  child.  Menstruation  began  at 
twelve  years,  and  ceased  a  year  before  the  girl  came  under 
observation. 

In  1890  the  patient  had  epidemic  influenza,  without  re- 
markable consequences.  The  present  trouble  began  in  that 
year.     Late  in  March  of  1890  she  wasrunning'along  a  wet 


250  yj^R  VO  us  DISEASES. 

boardwalk,  when  she  slipped  at  the  end  and  fell,  striking 
the  back  of  her  neck  on  the  edge  of  the  last  board  She 
had  to  be  assisted  to  rise,  and  complained  of  headache  for 
several  days.  About  a  week  later  she  tripped  in  the  grass 
and  fell,  causing  a  green-stick  fracture  of  the  left  radius. 
As  soon  as  the  nature  of  the  accident  was  understood,  a 
plaster-cast  was  put  on  the  arm,  and  soon  afterward  it  was 
observed  that  the  hand  had  begun  to  "draw  up,"  and  that 
to  extend  it  was  extremely  painful.  This  gave  rise  to  no 
suspicion,  but  when  the  cast  was  taken  off  it  was  found  that 
the  arm  and  hand  were  entirely  paralyzed,  had  no  sensa- 
tion, a  very  poor  circulation,  had  shrunk  perce^^tibly,  and 
were  blue  and  mottled. 

The  spine  was  examined,  and  is  said  to  have  been  sensi- 
tive in  the  upper  cervical  region.  The  girl  declared  that 
tapping  it  at  this  time  made  the  knees  tremble  and  ache. 
She  was  ordered  to  bed,  applications  of  ice  made  to  the 
spine,  and  bromides  and  other  medication  employed.  In  a 
few  days  she  became  extremely  nervous,  flighty,  and  imag- 
inative ;  had  to  have  the  room  dark,  obliged  everybody 
to  go  about  in  slippers,  and  objected  to  the  slightest  noise. 

Her  physician  concluded  the  trouble  to  be  hysterical, 
ordered  the  shutters  opened,  and  suggested  that  her  parents 
insist  upon  an  effort  to  move  the  hand.  The  child  set  her 
own  will  to  work  as  soon  as  she  was  assured  that  it  was 
possible,  and  in  a  few  days  was  using  the  limb  tolerably 
well,  and  was  on  her  feet  again,  though  weak.  The  hand 
still  remained  partially  flexed,  and  rather  uncertain  in  its 
movements  for  some  time  afterward. 

Late  in  June  she  was  taken  to  a  farm  in  the  country, 
where  she  steadily  regained  her  strength  and  flesh,  playing 
with  other  children,  until  the  middle  of  July,  when  there 
were  four  excessively  hot  days.  Athough  she  was  kept  as 
quiet  as  could  be,  on  the  fourth  day  the  left  arm  dropped 
helpless  and  began  to  contract,  and  later  to  shrink,  and 


HYSTERICAL  CONTRACTURES.  251 

became  remarkably  blue  and  mottled.  Early  next  morning 
she  staggered  into  her  mother's  room,  complaining  of  dizzi- 
ness. Her  mother  caught  her  in  her  arms,  and  from  that 
time  she  has  never  stood  erect  upon  her  feet  without  aid. 
She  was  put  in  bed,  and  had  a  fever  in  a  few  days,  with  a 
temperature  of  from  101°  to  102°.  She  was  extremely 
excitable,  and  had  a  variable  tendency  to  fancy  shapes  and 
sounds  about  her.  Within  a  few  days  the  temperature 
became  normal.  By  and  by  she  sat  up  and  played,  using 
both  hands  and  arms  freely,  and  could  put  out  either 
foot  to  draw  to  her  the  playthings  she  dropped  from  her 
hands.  Still  she  could  not  stand.  Twice  she  forgot,  and 
springing  up  to  answer  a  call  dropped  instantly  on  the  floor. 
After  waiting  for  two  weeks,  thinking  she  would  recover 
the  use  of  her  legs,  her  parents  took  her  home  to  her  own 
doctor.  There  was  at  this  time  an  almost  daily  percep- 
tible loss  of  power  in  the  legs,  and  sensation  also  began  to 
go,  which  had  not  happened  before. 

On  October  1st,  twenty-four  days  after  the  last  fall,  the 
child  was  Avithout  sensation  below  the  knees.  Her  tem- 
perature averaged  from  time  to  time  from  101°  to  102°, 
with  a  very  rapid  pulse,  and  a  slight  return  of  the  excit- 
able, flighty  condition.  The  former  treatment  was  repeated, 
and  again  motion  Avas  restored  in  ten  days.  The  hand  at 
this  time  measured  three-quarters  of  an  inch  less  in  circum- 
ference at  the  first  joint  than  the  other,  and  the  skin  peeled 
deeply  from  the  ends  of  the  fingers  and  thumbs,  so  as  in  a 
measure  to  suggest  the  kind  of  change  that  is  seen  after  an 
attack  of  scarlet  fever. 

From  this  time  on  there  was  a  steady  gain  until  Septem- 
ber 6th,  when  one  day  she  lost  her  balance  and  fell  back- 
ward off  her  seat,  striking  the  back  of  her  neck,  a  little  to 
the  right,  at  the  base  of  the  l)rain,  on  the  sharp  edge  of  a 
sill — not  a  door-sill,  but  a  part  of  the  frame  of  the  barn 
where  she  had  been  taken  for  her  anuisement.     The  blow 


252  NER  VO  US  DISEASES . 

raised  a  large  lump,  and  was  really  severe.  She  fell  doubled 
up  between  the  step  aud  the  wall ;  aud  the  other  children 
pulled  her  out  rather  violently,  and  she  complained  that 
they  hurt  her  back  in  so  doing.  This  was  late  in  the  fore- 
noon. She  ate  no  dinner  that  day,  and  looked  pale  and 
haggard,  but  said  nothing  about  the  matter.  Very  soon 
afterward  it  was  observed  that  there  was  no  motion  in 
either  feet  or  legs,  and  that  the  latter  had  begun  to  draw 
up;  but  the  arms  and  hands  were  still  untouched  by  this 
disastrous  trouble. 

By  October  15th  the  knees  were  at  a  slightly  acute  angle, 
and  still  drawing  up.  Any  attempt  at  extension  caused 
great  pain.  The  girl  was  able  to  sit  up,  but  complained 
that  her  back  was  constantly  tired.  Finally  a  rung  Avas 
sawed  out  of  her  low  chair  in  order  to  let  the  feet  draw 
back  under  it.  On  October  19th,  while  sitting  busily  cro- 
cheting, her  right  hand  fell  suddenly  in  her  lap,  and  a 
minute  later  the  left,  and  neither  moved  again  for  twenty- 
seven  months.  In  less  than  a  week  both  arms  had  drawn 
up  to  a  right-angle,  the  fingers  and  wrist  were  bent  in 
flexion  upon  the  arms,  and  both  arms  and  legs  were  totally 
devoid  of  sensation.  After  this  the  child  could  not  sit  up 
any  more,  pain  in  the  spine  being  constant  at  the  lower  part, 
chiefly  in  the  dorso-lumbar  region.  The  sphincter  muscles 
of  the  bladder  and  rectum  were  at  this  time  sometimes  in 
a  relaxed  condition  and  allowed  everything  to  pass,  and  at 
other  times  violently  contracted,  so  as  to  make  the  discharge 
of  urine  or  feces  for  the  time  impossible. 

For  days  the  little  patient  was  an  entirely  helpless  per- 
son, except  for  the  ability  to  move  her  head  from  side  to 
side.  About  November  11th  chloroform  was  fully  admin- 
istered, but  the  tendons  did  not  relax,  and  it  required  the 
efforts  of  two  physicians  to  extend  the  arms  and  legs,  so  as 
partially  to  straighten  the  joints.  Next  day  there  was  a 
decided  change  for  the  worse.     Spasmodic  contractions  of 


HYSTERICAL  CONTRACTURES.  253 

the  neck  and  pectoral  muscles  set  in.  The  girl  could  not 
swallow  even  liquids.  Food  was  then  given  by  injections 
for  some  days.  It  required  an  hour  for  her  to  relieve  her 
bladder,  and  at  this  time  the  urine  was  heavily  charged  with 
phosphatic  deposits,  so  that  in  a  pint  they  were  one  or  two 
inches  deep. 

All  sorts  of  things  happened  in  the  next  few  weeks.  The 
tongue  was  drawn  to  one  side  on  occasions,  so  that  the  teeth 
rubbed  the  skin  off  it.  The  child  became  blind  and  nearly 
entirely  deaf.  The  pectoral  muscles  occasionally  contracted 
powerfully,  so  as  to  draw  the  arms  across  the  chest,  or  the 
chest  into  a  deep  concave,  making  full  breathing  impossi»^ 
ble.  On  other  occasions  the  head  was  jerked  violently 
from  side  to  side,  even  in  sleep,  and  the  girl  would  rise 
from  the  pillow  and  move  to  and  fro  with  a  pendulum-like 
motion,  and  then  fall  back,  still  asleep,  or  apparently 
exhausted. 

There  were  constant  spasms  of  the  diaphragm,  during 
which  it  seemed  that  the  child  would  never  breathe  again. 
Her  temperature  during  this  time  varied  from  95°  to  101", 
sometimes  making  this  extreme  excursus  within  two  hours, 
the  pulse  being  then  from  130  to  180,  and  respirations  be- 
yond the  possibility  of  counting.  Meanwhile  emaciation 
increased ;  sleep  became  almost  impossible  (even  with 
copious  doses  of  codein),  seldom  lasting  more  than  from 
thirty  to  sixty  minutes.  At  this  time  it  was  necessary  to 
tie  her  head  down  to  give  her  any  rest  at  all.  Ice  was 
kept  on  the  whole  length  of  the  spinal  cord,  an  ice-cap 
was  placed  on  the  head,  and  in  these  measures  the  patient 
seemed  to  find  more  relief  than  in  anything  else.  There 
was  a  broad  red  band  across  her  forehead,  very  difficult 
to  describe,  and  deep  streaks  down  both  her  cheeks,  of  an 
intense  red.  Her  eyelids  sometimes  remained  open  for 
long  periods,  and  at  others  were  shut  for  hours,  so  that 
she  could  not  open  them.     Again,  the  eyes  themselves 

22 


254  NERVOUS  DISEASES. 

would  move  independently,  sometimes  one  rolling  upward 
and  the  other  downward,  or  one  outward  and  one  inward, 
producing  a  most  extraordinary  appearance.  ''  Every  hour 
for  weeks,"  said  her  mother,  "  we  expected  to  see  her  draw 
her  last  breath ;  nor  were  we  alone  in  the  belief  that  it  was 
impossible  that  she  should  come  out  of  this  condition  and 
live."  "  I  should  have  mentioned  also,"  added  her  mother, 
' '  to  withhold  nothing  of  interest,  that  she  passed  entire 
days  in  a  comatose  condition,  and  others  in  a  state  that 
could  more  aptly  be  described  as  a  deep  sleep." 

During  this  long  period  the  girl  was  fed  entirely  by  the 
bowel,  and  was  rubbed  with  oil  and  brandy,  the  throat  and 
mouth  being  sprayed  with  water  and  glycerol  every  few 
minutes.  On  December  16th  came  what  is  described  by 
her  parent  as  the  crisis.  She  had  alarming  spasms  of  the 
diaphragm,  much  longer  than  the  preceding  ones.  Then 
they  suddenly  ceased,  and  did  not  return  for  three  years. 
There  was  a  slight  relaxation  at  this  time  of  all  of  the 
contractions,  and  the  patient  was  rather  more  comfortable. 
In  a  few  days  afterward  she  began  to  swallow  a  little,  but 
at  this  time  she  was  entirely  blind  ;  she  had  also  no  sense  of 
taste.  The  smallest  amount  of  water  swallowed  caused 
extreme  pain,  and  the  slight  effort  of  masticating  or  swal- 
lowing food  gave  rise  to  profuse  perspiration  and  indescrib- 
able weakness. 

It  was  characteristic  of  the  hysterical  nature  of  the  case 
that  the  girl  could  sometimes  be  fed  by  means  of  spoons 
which  were  of  some  unusual  form,  letting  her  feel  the  pat- 
terns with  her  lips  or  tongue.  About  this  time  she  began 
to  take  potassium  iodide,  increasing  the  dose  as  fast  as  the 
stomach  could  bear  it. 

On  January  9, 1891,  she  was  able,  with  effort,  to  tell  the 
number  of  fingers  held  up  close  to  her  eyes,  and  on  Janu- 
ary 16th  could  distinguish  outlines  and  bright  colors. 

On  March  1st  her  sight  became  good  in  the  right  eye; 


HYSTERICAL  CONTRACTURES.  255 

it  had  never,  until  very  lately,  returned  fully  to  the  left 
eye.     She  could  see  things  less  distinctly  with  the  latter. 

Fearing  the  effect  of  heat  upon  her  (as  she  manifestly 
lost  ground  when  overheated  ;  her  legs  drew  up  more  forci- 
bly, and  she  lost  flesh  as  the  warm  days  came  on),  her 
parents  were  advised  to  take  her  to  the  mountains  for  the 
stimulus  of  a  rarer  atmosphere  and  the  coolness  of  the  high 
altitude.  A  cot  was  made,  Avhich  was  swung  on  solid  rub- 
ber rope  to  save  jarring,  and  she  Avas  carried  up  Roan 
Mountain,  6394  feet  high.  She  began  at  once  to  sleep 
well,  eat  well,  and  move  with  ease.  At  this  time  the  hands 
were  still  twisted  together  at  the  wrists,  and  tightly 
clenched.  She  also  had  the  embarrassing  symptom  of 
violent  protrusion  of  the  rectal  mucous  membrane,  which 
would  come  down  suddenly  in  her  sleep.  If  it  was  not 
pushed  into  place  at  once,  it  seemed  to  be  caught,  and 
then  it  became  congested,  and  its  return  was  exceedingly 
difficult. 

At  this  time  the  legs  were  still  contracted  and  motion- 
less ;  both  knees  were  subdislocated  ;  the  left  foot  was  laid 
up  over  the  right  thigh,  and  the  right  foot  on  the  left  thigh. 
Both  feet  were  draw^n  into  a  sharp  curve,  and  the  toes  were 
drawn  under  so  tightly,  and  so  close  together,  that  it  was 
impossible  to  draw  a  rag  under  or  between  them.  Quan- 
tities of  iron  and  potassium  iodide  were  given,  with  occa- 
sional cessation  of  the  treatment  to  let  the  stomach  recover 
its  tone. 

The  child's  parents  remained  on  the  mountain  Avith  her 
from  June  6th  to  October  16th,  and  then  returned  to  her 
native  town.  During  these  four  months  she  had  gained 
thirty-three  pounds  in  Aveight,  having  weighed  in  June 
forty-five  pounds  and  in  October  seventy-eight  pounds. 
On  her  return  she  instantly  ceased  gaining  flesh,  was  again 
attacked  by  influenza,  and  Avas  Avretchedly  AA^ak  all  AA^nter  ; 
she  had  to  be  watched  closely,  and  continually  kept  cool, 


256  NER  VO  US  DISEASES. 

insisting  upon  tlie  windows  being  open  day  and  night, 
although  the  thermometer  was  often  at  zero.  Her  physi- 
cian urged  her  parents  to  hasten  away  early  in  the  spring, 
and  accordingly  they  started  in  April,  waited  a  month  at 
the  foot  of  Koan  Mountain  for  the  snow  to  melt,  and  moved 
over  the  mountain  to  Glen  Ayres,  4500  feet  above  the  sea- 
level,  on  the  south  slope.  As  before,  the  girl  began  to  pick 
up  at  once.  Sensation,  which  had  crept  down  from  the 
shoulders  the  previous  summer  nearly  to  the  elbows,  began 
to  be  manifest  below  the  elbows. 

In  June,  1892,  menstruation  began.  The  girl  was  then 
twelve  years  and  eight  months  old.  There  was  no  gen- 
eral disturbance  of  the  system  at  this  time,  beyond  slight 
backache  and  headache,  and  no  hysterical  manifestation. 
The  menstruation  continued  with  perfect  regularity  and  in 
good  quantity  until  December,  1893,  when  it  ceased. 

There  has  never  been  any  unnatural  discharge  or  any 
complaint  of  pain  or  uneasiness  at  the  menstrual  period, 
except  that  caused  occasionally  by  retention  of  urine. 
There  was  a  general  access  of  strength  and  flesh  during 
the  summer  of  1892,  and  in  September  the  family  moved 
a^ain  to  the  summit  of  the  mountain  for  the  winter,  fully 
determined  to  test  the  value  of  altitude  in  the  child's  case. 
In  the  meanwhile,  unable  to  use  her  hands,  the  little  one 
learned  to  write  and  draw  beautifully  with  pen  and  pencil 
in  her  mouth,  holding  them  firmly  on  the  right  side  between 
her  teeth,  and  moving  the  head.  She  complained  that  the 
other  side  of  her  mouth  was  "  left-handed."  She  con- 
ducted in  this  astonishing  manner  a  large  correspondence 
entirely  by  herself,  except  the  folding  of  the  letters  and 
placing  them  in  the  envelopes,  the  hands  being  still 
clenched  and  twisted  as  I  have  described.  Fig.  10  illus- 
trates her  mode  of  writing,  and  Fig.  11  the  writing,  I 
have  since  seen  her  write  and  draw  with  the  pencil  or  pen 
held  bv  the  teeth  as  described. 


HYSTERICAL  CONTRACTURES.  257 

Fig.  10. 


I 


1 


E.  M.  H.  writing  with  pen  held  in  mouth. 
Fig.  11. 


With  pen  in  teeth,  1892. 
22* 


258  NER  VO  US  DISEASES. 

The  winter  was  extremely  severe  on  the  mountains. 
During  January  it  was  impossible  to  keep  the  temperature 
in  the  sitting-room  up  to  32°.  Most  of  the  time  it  was  from 
20°  to  30°.  For  some  weeks  previously  the  girl  had  been 
able  to  move  her  right  thumb  a  little,  and  on  January  13th 
she  opened  that  hand  and  moved  all  the  fingers,  but  could 
not  separate  the  w^rists,  which,  if  I  have  made  the  matter 
clear,  I  should  have  described  as  being  pressed  violently 
one  against  the  other. 

January  loth,  two  days  later,  she  opened  the  left  hand 
and  moved  all  the  fingers,  and  got  the  hands  apart.  In  a 
very  few  days  afterward  she  was  using  them  both  for 
writing  and  knitting,  somewhat  awkwardly,  of  course. 
Sensation  began  to  creep  down  below  the  elbows  ;  her  flesh 
increased  rapidly,  her  color  became  good,  and  there  was 
more  warmth  of  the  extremities.  Her  legs  were  still 
motionless,  subluxated  at  the  knees,  and  violently  drawn, 
as  before  described. 

Fig.  12. 


^^m^ 


With  pen  in  riglu  haiui,  March  19,  IJS'.i:?. 


In  April  she  was  taken  to  Professor  Allen,  of  Indian- 
apolis, who  cut  the  tendons  in  the  groins  and  under  the 
knees.  The  joints  had  grown  out  of  shape,  and  the  skin 
under  the  knees  had  contracted  and  hardened  so  much 


HYSTERICAL  CONTRACTURES.  259 

after  thirty-two  months'  flexion  as  to  make  full  extension 
dangerous.  A  moderate  amount  of  chloroform  came  near 
proving  fatal,  and  so  the  cords  were  cut  in  four  operations, 
whiskey  being  given  beforehand.  Then  extension-braces 
were  fitted  to  be  worked  with  ratchets,  and  the  patient  was 
brought  back  to  the  mountain-top.  She  soon  sat  up  in 
a  wheeled  chair,  rolling  it  with  her  own  hands,  and,  in 
fact,  became  a  picture  of  rosy,  plump  girlhood. 

In  August,  1893,  she  began  moving  her  feet  slightly, 
and  resolutely  practised,  with  the  aid  of  her  mother,  until, 
in  October,  she  could  move  the  sewing-machine  treadle  a 
little.  She  had  to  lift  her  legs  and  feet  Avith  her  hands, 
but  could  move  her  feet  and  toes.  There  was  still  at  this 
time  no  sensation  in  the  legs  below  the  groin,  but  it  was 
pretty  good  in  the  arms,  and  she  could  feel  a  needle  almost 
down  to  the  knuckles  of  both  hands.  The  knees  had 
been  forcibly  extended  daily  by  the  use  of  instruments 
until  the  angle  was  extremely  slight.  This  process  was 
very,  painful,  always  giving  rise  to  great  distress  in  the 
lumbar  vertebrae.  Several  attempts  to  stand  with  assistance 
caused  extreme  torment  in  the  same  region. 

On  September  30th  the  child  was  taken  in  a  buckboard 
wagon  several  hundred  yards,  and  again  on  October  29th. 

On  November  2d  she  appeared  languid  ;  her  back  hurt 
her  more ;  she  could  not  sit  up,  but  preferred  to  lie  still  all 
day.  She  was  carried  down  stairs  as  usual  to  lie  on  a 
couch,  and  the  stretching  at  that  time  was  omitted  and 
never  resumed.  After  this  she  did  not  sit  up.  Two  weeks 
later  there  was  a  slight  menstrual  discharge ;  her  appetite 
failed,  and  her  strength  gave  way.  For  the  first  time  in 
five  months  it  was  necessary  to  put  ice-bags  on  the  back  of 
her  neck.     In  other  words,  she  had  a  very  serious  relapse. 

She  could  not  be  carried  down  stairs  until  May.  Her 
parents  had  intended  to  move  to  Roan  Station  for  the 
winter,  but  did  not  think  it  advisable  to  disturb  her. 


260  ^'^^R  VO  US  DISEASES. 

Violent  palpitation  of  the  heart  came  on ;  the  j^nlse  was 
160,  hard  and  bounding ;  the  temperature  was  only  97°  ; 
the  respiration  very  rapid.  At  this  time  the  physicians 
who  saw  the  girl  were  again  satisfied  that  it  was  impossible 
that  she  could  live  much  longer. 

On  January  12, 1894,  she  had  serious  ulcerations  of  the 
mouth  and  throat ;  her  breathing  became  as  rapid  as  from 
90  to  160  per  minute ;  her  pulse  quick,  weak,  and  wiry. 
The  urine  was  exceedingly  scanty  and  dark.  The  legs  be- 
came again  motionless  ;  the  cords  contracted  at  the  knees  ; 
the  hips  and  the  arms  were  still  free,  as  they  had  been 
before,  but  increasingly  numb. 

At  this  time  there  came  on  also  a  great  difficulty  in 
speech.  Ice  was  now  used  on  the  head  also,  and  again  the 
child  desired  to  have  all  light  and  sound  excluded.  On 
January  20th  she  spoke  once:  "Mamma,"  she  said,  "it 
hurts,"  and  never  afterward,  up  to  the  time  of  her  falling 
under  my  own  care.  Xor,  in  fact,  did  she  make  in  this 
period  an  articulate  sound,  asleep  or  awake.  The  vocal 
bands  were  relaxed  at  this  time,  and  are  said  to  have  been 
ulcerated.  The  legs  were  drawn  up  almost  to  the  body, 
but  there  never  was  as  much  contraction  of  the  thigh  on 
the  pelvis  as  of  the  leg  on  the  thigh. 

The  girl  could  still  express  herself  in  writing  with  her 
hands,  but  complained  that  they  were  weak  and  numb,  and 
she  feared,  as  she  wrote,  that  they  were  "  going  again." 
On  February  10th  she  had  violent  contraction  of  the  ab- 
dominal muscles  following  an  enema ;  convulsive  shudder- 
ings  for  a  time  ran  over  her  body,  and  her  hands  and  arms 
in  an  hour  were  completely  paralyzed. 

From  February  10th  till  March  3d  she  had  no  discharge 
from  her  bowels.  On  February  14th  she  had  great  diffi- 
culty in  expiration  ;  she  would  fill  her  chest  to  the  utmost 
degree  with  air,  and  then  remain  half  a  minute  without 
expelling  it,  and  finally  would  drive  it  out  in  jerking  whiffs, 
her  head  moving  violently  to  and  fro  as  she  did  so. 


HYSTERICAL  CONTRACTURES.  261 

At  this  time  there  was  great  difficulty  in  deglutition, 
and  occasionally  swallowing  was  followed  by  violent  con- 
vulsive efforts,  during  which  the  blood  would  fly  forcibly 
from  the  nose  and  mouth.  Two  hours  or  more  were  re- 
quired to  swallow  two  or  three  ounces  of  milk,  and  nour- 
ishment was  mainly  given  by  enemata.  At  this  time  some 
effort  was  made  to  knead  the  abdomen,  but  every  attempt 
caused  contractions  of  the  bowels  so  violent  that  the  mus- 
cles would  spring  into  stiff  cords,  and  remain  thus  for  hours ; 
while  the  urine  had  to  be  drawn,  and  was  brown  and  ex- 
ceedingly offensive,  but  without  blood. 

On  March  3d  there  was  a  temporary  cessation  of  con- 
tractions, and  the  bowels  were  moved,  and  this  was  the 
last  motion  until  March  29th.  During  all  this  time  the 
patient  was  fed  chiefly  by  enema ;  nothing  passed  away, 
everything  being  absorbed  with  astonishing  ease. 

After  February  10th  all  communication  was  made  by 
the  eyelids  ;  the  child  could  no  longer  use  her  hands  or  her 
speech,  even  in  the  faintest  whisper ;  but  when  she  wished 
to  indicate  anything  she  would  wink  several  times.  Cards 
were  held  up  containing  the  alphabet,  and  when  the  right 
letter  was  reached  she  would  wink. 

On  March  12th  continuous  convulsions  of  the  head, 
arms,  bowels,  jaws,  and  tongue  set  in.  All  food  and  drink 
were  given  by  the  bowel  and  by  outward  application. 
Again  there  was  a  deep  crimson  flush  all  over  the  head, 
and  it  was  needful  continuously  to  keep  ice  on  the  neck 
and  head.  The  facial  and  temporal  arteries  were  of  the 
size  of  large  lead-pencils ;  all  were  throbbing  so  violently 
that  their  pulsation  could  be  counted  across  the  room. 

On  March  22d  the  convulsions  were  so  violent  as  to  re- 
quire men  to  hold  the  child,  and  at  this  time  it  was  observed 
that  the  urine  became  of  an  extraordinary  odor,  described 
to  be  like  that  of  the  cat.  On  March  25th  she  was  totally 
deaf,  partially  blind,  and  entirely  speechless.     She  could 


262  NER  VO  US  DISEASES. 

not  feel  a  ueedle  anywhere  in  the  body,  except  in  the  lips. 
The  skin  was  rough  all  over  the  body,  and  looked  and  felt 
like  sand  paper,  presenting  an  indescribable  dry  roughness. 
At  this  time  any  attempt  to  comb  the  hair  was  foUow^ed 
by  bleeding  from  the  scalp,  and  the  hair  fell  out  in  hand- 
fuls.  Emaciation  became  extreme.  All  of  this  time  the 
girl  had  an  exceeding  sensitiveness  as  to  heat,  and  the 
breathing  would  become  terribly  difficult  if  the  windows 
were  closed,  so  that  her  family  were  obliged  to  keep  the 
sash  up  and  the  transom  over  the  door  open  although  they 
were  on  the  top  of  the  mountain,  with  the  thermometer 
down  in  the  neighborhood  of  zero.  Her  nurses,  as  may 
be  imagined,  suffered  severely  under  this  regime. 

On  March  29th  her  convulsions  ceased.  On  April  4th 
she  had  discharges  of  green  and  yellow  pus,  in  remarkable 
quantities,  from  the  ears  and  nose,  as  well  as  from  one  or 
two  abscesses  which  had  to  be  opened  in  various  parts  of 
the  body  ;  one  on  the  side  of  the  neck  appeared  to  be  very 
serious.  Shortly  after  this  her  sight  began  to  return,  and 
it  was  soon  found  that  she  was  reading  the  motions  of  her 
attendant's  lips,  although  stone-deaf,  and  very  soon  she 
understood  every  syllable,  when  the  light  was  good  and 
faces  were  turned  squarely  tow^ard  her.  From  this  time 
for  months  she  continued  to  improve  in  this  accomplish- 
ment. Her  family  learned  for  her  use  the  deaf-and-dumb 
alphabet,  so  that  she  communicated  with  them  either  by 
speaking  with  her  own  lips,  so  that  her  mother  read  them, 
or  by  looking  at  the  lips  of  those  talking,  or  by  seeing  the 
motion  of  her  mother's  fingers,  when  her  sight  at  length 
was  better.  Following  this  there  was  a  period  of  many 
months  during  which  she  was  subject  to  curious  and  fre- 
quent attacks  of  congestion  of  the  superficial  veins  all  over 
the  body.  The  whole  body  would  sometimes  become  mot- 
tled blue,  as  if  a  coarse  blue  veil  were  drawn  over  it;  the 
lips  and  eyelids  would  grow  almost  black,  and  breathing 


HYSTERICAL  CONTRACTURES.  263 

become  exceedingly  difficult.  It  was  then  necessary  to  give 
stimulus  quickly,  and  to  sponge  the  body  with  cold  and  hot 
water,  and  renew  the  hot-water  bottles,  and  do  quick  work, 
in  order,  as  it  seemed  to  her  family,  to  save  the  child  from 
death.  A  little  excitement,  or  a  too  warm  room,  would 
in  a  minute  bring  on  one  of  these  remarkable  attacks. 
The  last  attack  of  this  sort  occurred  in  September. 

Early  in  May  she  began  to  chew  a  little  ;  she  could  swal- 
low no  solids,  and  only  from  one-eighth  to  one-fifth  of  the 
fluids  attempted  ;  the  diet  was  still  chiefly  by  enema.  On 
May  2d  Dr.  Allen,  who  saw  her,  expressed  his  surprise  that 
she  was  still  alive,  and  it  did  not  seem  possible  then  that 
she  could  live  from  hour  to  hour,  although  she  had  been 
really  convalescing  for  nearly  a  month.  She  was  breath- 
ing entirely  with  the  diaphragm  at  this  time ;  the  lungs 
were  congested  and  full  of  rales,  and  in  the  costal  region 
quite  motionless. 

From  this  time  there  were  gradual  gains,  and  it  seems 
useless  to  repeat  the  roll  of  extraordinary  hysterical  symp- 
toms. Early  in  June  she  began  moving  the  fingers  of  the 
left  hand.  On  June  13th  she  was  able  to  "  shake  hands 
all  around,"  as  she  said,  and  could  swallow  a  little  solid 
food,  and  nearly  all  liquids.  On  June  19th  she  wrote  her 
name  for  Dr.  Allen  and  for  her  mother,  and  respiration 
began  to  be  deeper  and  more  comfortable,  and  she  was  more 
cheerful  and  happy.  On  September  13th  she  was  moved 
down  to  Roan  Station,  2650  feet  above  sea-level.  On  Sep- 
tember 28th,  the  third  consecutive  warm  day,  the  mercury 
being  at  80°,  a  violent  inflammation  of  the  eyeballs  and  eye- 
lids and  congestion  of  the  entire  face  and  neck  came  on, 
and  lasted  until  the  weather  changed,  a  week  later.  At 
this  time  the  child  began  to  make  her  right  hand  hold  the 
work  for  her  left  hand.  The  left  hand  and  arm  were  quite 
free  and  vigorous,  although  there  was  no  feeling  as  yet  in 
any  part  of  them. 


264 


NERVOUS  DISEASES. 


Every  warm  day  in  October  and  November  brought  back 
symptoms  similar  to  those  already  described,  but  the  prompt 
use  of  cold  applications  stopped  the  attacks. 

On  November  26,  1894,  four  years  and  three  months 
after  the  second  injury,  and  four  years  and  nearly  eight 
months  after  the  first  injury  on  the  boardwalk,  and  thirteen 
months  after  the  last  relapse,  the  sight  was  good  in  the 
right  eye ;  dim  in  the  left  eye.  The  ear-drums  were  said 
to  be  congested,  but  she  distinguished  many  sounds  through 
a  trumpet,  if  one  spoke  loudly.  Often  she  could  not  dis- 
tinguish both  syllables  of  a  two-syllable  word,  not  even  her 
own  name.  After  the  first  efibrts  her  deafness  again 
seemed  to  increase.  At  this  time  she  heard  rather  better 
on  cold  days  than  on  warm  days.  High-pitched  voices 
hurt  her. 


Fig.  lo. 


'^lu.  (jSW  ^Tk.  C^, 
With  pen  in  left  hand,  November,  1894. 

On  examination  of  the  ears  no  perforation  of  the  drums 
was  found,  in  spite  of  the  free  discharge  from  the  ears. 
Inflation  of  the  Eustachian  tubes  was  attempted,  but  could 
not  be  borne.  No  effort  at  articulation  was  possible.  Com- 
paratively little  food  could  be  taken,  but  it  was  swallowed 
more  freely,  and  some  food  was  still  given  by  injection. 

Although  there  was  a  gradual  gain  in  flesh  and  strength, 
sensation  returned  late  in  both  arms  above  the  elbows. 
The  right  hand  recovered  its  motion  and  held  the  work  so 


HYSTERICAL  CONTRACTURES.  265 

as  to  enable  her  to  use  the  needle  with  her  left  hand ;  or 
else  she  would  hold  the  pen  in  the  right  hand  for  writing, 
and  guide  the  less  active  part  Avith  the  left  hand,  seizing 
it  at  the  wrist. 

The  limbs  remained  unchanged,  the  feet  crossed  and 
drawn.  The  patient  lay  nearly  all  the  time  at  this  period 
on  the  right  side,  and  could  not  bear  lying  on  the  spine  at 
all.  There  were  a  great  many  rales  in  the  right  lung,  and 
what  was  described  as  emphysema  and  congestion,  but  the 
pulmonary  condition  was  better  than  a  month  before.  The 
temperature  was  usually  half  a  degree  above  normal ;  the 
pulse  always  a  hundred  or  more,  and  easily  increased.  The 
girl  at  this  time  could  not  bear  a  temperature  of  over  60°, 
whether  natural  or  artificial,  and  had  to  have  plenty  of  air. 
The  stomach  could  not  hold  much  food  at  a  time ;  efforts 
to  feed  her  produced  contraction  and  pain  and  a  threat  of 
return  of  bad  symptoms.  The  bowels  were  only  moved  by 
copious  enemata ;  the  discharges  were  slow  and  difficult,  by 
reason  of  weakness.  A  good  deal  of  mucus  passed,  fre- 
quently in  large  shreds.  The  bladder  was  subject  to  invol- 
untary and  frequent  passages.  The  child  was  aware  when 
these  would  begin,  and  could  sometimes,  though  not  often, 
start  them,  but  could  not  stop  them.  The  skin  had  become 
natural  in  texture  and  of  a  good  color.  There  had  been 
no  bedsores  recently ;  there  had  been  one  on  the  head  in 
March,  but  it  had  healed  up  very  readily.  The  right  ear, 
I  should  say,  had  a  large  piece  worn  out  of  the  rim — a 
deep  notch  caused  by  the  jerking  of  the  head  on  the  pillow 
in  February  and  March  of  the  year  before.  This  had  long 
since  healed.  The  spine  was  very  tender  ;  the  child  could 
not  bear  to  have  it  touched ;  the  muscles  alongside  of  it 
were  also  very  sensitive. 

The  mother  added  that  at  this  time  the  girl  Avas  fifteen 
years  of  age ;  that  she  had  grown  symmetrically  in  the 
main  ;  that  if  she  ever  walked  she  would  not  be  noticed  as 

23 


266  NERVOUS  DISEASES. 

under-developed  anyNvhere.  The  feet  were  rather  sraall^ 
but  not  deformed ;  and  the  liands,  like  the  feet,  were  of 
good  shape.  The  child's  mind  was  phenomenally  clear  and 
keen,  her  memory  inexhaustible,  and  her  patience  very 
great.  Her  intelligence,  as  her  mother  said,  was  almost 
clairvoyant. 

In  December,  1894,  this  child  was  brought  to  me :  a 
bright,  exceedingly  intelligent,  very  pretty  girl,  less  thin 
about  the  face  than  elsewhere,  and  sufficiently  developed 
for  her  time  of  life.  There  was  general  emaciation, 
which  was  most  marked  in  the  right  arm ;  her  weight 
at  this  time  was  about  sixty  pounds.  There  was  great  con- 
traction of  the  legs  upon  the  thighs,  so  that  the  heels  lay 
up  against  the  buttocks,  and  the  feet  were  crossed,  one 
ankle  over  the  other.  The  contraction  of  the  thighs  upon 
the  pelvis  was  not  much  beyond  a  right-angle.  The  knees 
were  closely  drawn  together.  It  was  impossible  forcibly 
to  straighten  the  legs,  even  after  complete  use  of  chloro- 
form, and  the  joints  were  secondarily  affected,  the  knees 
partially  luxated.  The  skin  of  the  limbs  about  the  ankles 
and  knees  was  thickened,  shining,  and  smooth,  and  behind 
the  knee  was  excessively  hard  and  tough,  as  though  there 
was  infiltration  of  the  areolar  tissues,  it  being  difficult  to 
feel  the  tendons  distinctly.  The  temperature  of  the  legs 
was  good  above  the  knees,  but  the  feet  were  exceedingly 
cold,  although  there  was  nothing  remarkable  about  the 
nutrition  of  the  nails,  either  in  the  feet  or  hands.  The 
cutaneous,  muscular,  and  tendinous  reflexes  were  all  absent, 
and  pins  could  be  stuck  in  anywhere  below  the  hips  with- 
out evidence  of  pain.  Neither  was  there  any  thermal  sense 
below  the  groin  or  in  the  right  arm. 

Over  and  above  the  contraction  in  the  muscles  there 
appeared  to  be  also  a  true  paralysis  of  motion  below  the 
knee,  as  the  child  was  incapable  of  making  the  slightest 
exhibition  of  movement  of  the  toes  or  ankles.     She  could 


HYSTERICAL  CONTRACTURES.  267 

lift  and  hold  both  arms  up  from  the  bed.  She  could  not 
grasp  anything  with  either  hand,  but  with  a  little  man- 
agement and  support  could  hold  a  book.  There  was 
incomplete  loss  of  power  in  the  upper  limbs  to  localize  a 
touch  or  to  detect  extremes  of  heat  and  cold.  Pain  was 
here  unfelt,  and  there  was  analgesia  over  the  whole  trunk. 
The  biceps  tendon-jerk  and  the  muscle-jerk  of  the  exten- 
sors of  the  hand  were,  hoAvever,  present.  Respiration  was 
normal,  about  eighteen  to  the  minute ;  the  heart  lungs, 
and  bowels  were  natural ;  there  was  no  evidence  of  organic 
disease  in  the  abdomen  or  elsewhere  ;  the  urine  was  normal. 
The  sight  was  good  at  this  time;  the  pupils  were  equal, 
moderately  dilated,  and  reacted  well  to  light  and  in  accom- 
modation. 

Fig.  H. 

With  pen  in  right  hand,  guided  by  left  hand,  March,  1895. 

The  child  declared  that  she  was  absolutely  deaf,  and 
made  no  attempt  to  speak.  She  read  her  mother's  lips 
with  ease,  and  mine  with  more  difficulty,  explaining  that 
it  was  on  account  of  the  moustache  which  hides  the  lips. 

Dr.  Archibald  G.  Thomson  examined  the  eyes  and  ears, 


268 


NER  VO  US  DISEASES. 


f 


% 


I 


HYSTERICAL  CONTRACTURES. 


269 


23^ 


270  ^'ER  VO  US  DISEASES. 

and  reported  as  follows :  O.  D.  The  media  are  clear ;  the 
pupil  clear  and  reacting  normally.  The  disc  is  normal  and 
color  good,  with  a  small  central  cup.  The  vessels  and  the 
fundus  are  normal,  4-1,  with  astigmatism.  The  fields  for 
form  and  color  are  normal.  O.  S.  The  same  as  the  right, 
except  that  the  astigmatism  is  a  little  higher.  The  mus- 
cular balance  is  slight.  Exophoria  due  to  weakness  of 
internal  rectus.  There  is  no  perforation  of  the  tympanic 
membrane  or  other  gross  lesion  of  the  ears. 

This  child  remained  at  rest  in  bed  on  her  side  always. 
To  be  on  the  back  caused  lumbar  ache.  Before  attempt- 
ing any  more  serious  step  I  endeavored  to  see  how  much 
movement  I  could  got  in  the  legs  by  the  continuous  use  of 
massage  and  faradic  electricity.  Very  soon  I  found  that 
there  was  a  slight  increase  of  sensation  everywhere ;  that 
the  limbs  were  beginning  again  to  grow ;  that  they  could 
be  drawn  down  each  day  a  little  lower ;  and  that  the  tem- 
perature of  the  feet  increased.  After  a  few  weeks  of  this 
treatment  we  ceased  to  gain  any  further  power  of  passive 
extension  of  the  limbs,  and  it  became  obvious  to  me  that, 
however  reluctantly,  I  must  resort  to  surgical  interference. 

Meanwhile  her  deafness  interested  me  greatly.  It  be- 
came rapidly  well  in  a  few  weeks.  Speech  came  back  with 
nearly  as  great  speed,  so  that  within  two  months  after  she 
fell  into  my  hands  she  could  speak  perfectly  well,  could 
hear  entirely  well,  could  see  as  well  as  ever,  and  was  recov- 
ering pretty  rapidly  the  use  of  the  left  arm  and  more  slowly 
of  the  right.  She  had  made  also  the  great  gain  in  motion 
and  sensation  in  the  low^er  limbs  above  the  ankles. 

At  this  time  I  requested  Dr.  Keen  to  make  section  of 
the  tendons  of  the  leg,  one  at  a  time,  and  this  was  done 
with  great  difficulty  under  profound  etherization ;  partial 
straightening  of  the  leg  was  accomplished  then  with 
weights  and  apparatus,  but  not  with  the  ratchet.  There 
has  been  a  gradual  extension  of  the  left  leg,  and  it  seems 


HYSTERICAL  CONTRACTURES.  271 

likely  that  it  will  coutiniie  to  improve,  although  the  pre- 
vious history  prepared  me  to  see  at  any  time  some  return 
of  hysterical  phenomena. 

On  April  26,  1895,  the  left  leg  was  so  much  better  that 
Dr.  Keen  thought  it  would  be  well  to  operate  on  the  right 
leg.  Sections  of  the  tendons  at  the  knee  were  made,  but 
it  was  found  that  the  head  of  the  tibia  was  so  luxated 
posteriorly  as  to  render  impossible  such  extension  as  had 
been  effected  on  the  opposite  side.  After  a  time  a  suitable 
apparatus  may  overcome  this  unfortunate  mechanical  diffi- 
culty ;  but  much  will  depend  on  her  endurance,  and  the 
gain  to  be  hoped  for  from  massage  and  electric  stimula- 
tion. 

Of  the  drawings.  Fig.  15  represents  the  attitude  of  the 
child  when  she  first  came  under  my  care ;  Fig.  16  the  re- 
sults obtained  by  massage  and  electricity  and  slight  exten- 
sion by  weights,  up  to  the  date  of  operation ;  and  Fig.  10 
the  position  in  which  she  placed  herself  when  using  her 
pencil  or  pen  with  her  mouth.  I  also  add  facsimiles  of 
parts  of  letters  written  with  her  hands  and  with  the  mouth 
(Figs.  11,  12,  13,  14). 

As  a  clinical  lesson  in  hysteria,  nothing  could  be 
more  instructive  than  this  record.  I  have  little  doubt 
that  early  isolation  and  resolute  treatment  would  have 
saved  these  years  of  distress.  Before  we  pass  on  to 
consider  the  gravest  symptom — the  general  contractures 
— I  desire  to  call  your  attention  to  the  fact  of  the  ab- 
sence of  changes  in  the  fields  for  color  and  form — surely 
an  amazino:  thinoj  in  a  case  with  so  much  anaesthesia. 
Unlike  the  case  first  spoken  of,  the  wasted  leg-muscles, 
especially  the  flexors,  can  be  stimulated  by  faradic  cur- 
rents ;  but  the  current  that  moves  them  so  slightly  is 
one  that  I  cannot  endure,  and  that  painfully  cramps 
any  of  my  muscles  on  which  I  test  it.   Electro-muscular 


272  NERVOUS  DISEASES. 

sensibility  is  very  much  lessened.  Those  muscles  of 
the  limbs  that  are  made  tense  by  long  contraction  of 
their  opponents  scarcely  stir  at  all  with  the  utmost 
power  of  a  battery,  but  when  I  relax  them  somewhat 
by  forcible  extension  of  the  limb  the  extensors  thus  re- 
laxed move  better  under  faradic  excitation.  This  cor- 
responds with  the  observations  reported  long  ago  by 
Morris  J.  Lewis  and  myself  to  the  effect  that  forcibly 
stretched  muscles  not  only  move  badly  under  electricity, 
but  also  do  not  feel  it  as  keenly. 

Had  not  these  muscles  been  once  Aveakened  by  tendon- 
section  and  their  sequent  elongation  I  should  have  begun 
hy  cutting  them.  I  felt  that  to  cut  these  tendons  again 
might  result  in  further  additions  to  their  lengths  and 
that  I  should  run  great  risk  of  seriously  disabling  their 
strength.  Xevertheless  I  was  forced  to  take  this  risk. 
In  a  long  experience  with  hysterical  contracture  I  have 
never  before  come  face  to  face  with  this  difficulty.  Of 
course,  there  is  always  the  after-resource  of  shortening 
the  tendons. 

Seeing  how  great  is  the  power  with  which  the  muscle 
in  a  state  of  spasm  contracts,  I  used  to  fear  that  its 
retraction  after  surgical  section  of  tendons  would  be 
excessive.  It  is  not  so.  Kather  does  the  sudden  ces- 
sation of  tension  appear  to  put  the  muscle  at  rest,  as 
though  the  resistance  were  one  of  the  means  of  keeping 
up  the  pull  made  by  the  muscle.  I  have,  in  fact,  lost 
the  fear  I  once  had  as  to  section  of  hysterical  muscles 
or  their  tendons. 

In  the  case  of  Miss  C,  of  which  I  have  already 
spoken,  there  was  extreme  pain  in  the  feet.  In  another 
case,  to  be  presently  described,  there  was  a  like  tor- 
ment.   In  the  one  just  now  related  there  has  been  little 


HYSTERICAL  CONTRACTURES.  273 

or  none.  The  reason  is  clear,  I  think:  while  the 
flexion  at  the  knee  is  in  this  latter  case  extreme,  that 
of  the  thigh  on  the  trunk  is  not.  In  Miss  C.^s  case 
not  only  were  the  knee-joints  at  the  utmost  angle  of 
acuteness  possible,  but  the  knees  touched  the  chin,  as 
was  nearly  the  case  in  the  man  in  Scott  Ward,  of  whom 
I  shall  have  more  to  say  by-and-by.  Now  flexion  at 
the  knee  only  relaxes  the  sciatic  nerve,  but  extreme 
flexion  of  the  thigh  on  the  trunk  keeps  the  nerve  tightly 
drawn  over  the  edge  of  the  notch,  and  may  well  be — 
indeed  was,  I  am  sure — the  chief  cause  of  pain  in  two 
of  the  cases  referred  to.  In  both,  tendon-section  and 
even  partial  extension  of  the  limb  speedily  put  an  end 
to  the  pain  in  question.  In  my  last  case  the  absence 
of  pain  is,  I  think,  due  to  the  lack  of  extreme  flexion 
of  the  thigh  on  the  trunk. 

There  are  other  interesting  features  in  this  case  with 
which  I  can  deal  but  lightly.  One  was  the  rare  symp- 
tom hysterical  deafness.  It  was  complete;  nor  did 
the  most  unexpected  and  violent  sounds  enable  me  to 
detect  the  patient  in  simulation.  With  the  use  of 
Malony's  ear-tubes  she  soou  began  to  hear  a  little,  and 
with  her  general  gain  the  deafness  speedily  departed. 
I  should  not,  above  all,  forget  to  say  that  for  the  first 
time  in  her  history  she  was  isolated  from  her  relatives. 

January  14,  1896.  From  May,  1895,  the  patient  was 
absent  in  the  country  until  September,  and  since  then  has 
been  in  the  care  of  Dr.  J.  K.  Mitchell.  Her  weight  has 
increased  seventeen  pounds.  She  has  lost  the  indescribable 
look  of  watchfulness  so  familiar  in  these  cases.  Her  will- 
power is  better ;  she  has  new  interests,  and  insists  hope- 
fully on  her  power  to  get  well.  Her  condition  w^as  at  this 
time  as  f ollow  s  : 


274  NER  VO  us  DISEASES. 

She  sits  in  a  wheel-chair,  which  she  moves  with  ease. 
She  is  rosy  and  in  good  condition,  and  weighs  101  pounds. 
Her  hand-movements  are  perfect.  The  legs  are  better  than 
ever,  and  every  movement  is  possible,  although  some  mus- 
cles move  less  well  than  others.  The  reflexes  are  all  pres- 
ent and  the  knee-jerk  and  ankle-jerk  are  present ;  all 
nerves  transmit  currents  normally  with  faradic  or  syne- 
soidal  currents ;  the  leg-muscles  show  slight  quantitative 
lessening  of  response.  The  legs  are  still  flexed  on  the 
thighs,  but  the  angle  thus  made  is  becoming  wider.  The 
feet  still  drop  a  little,  but  the  toes  have  perfect  flexion  and 
extension.  Sensation  is  nearly  perfect  in  all  its  forms.  Red 
blood-corpuscles,  4,200,000.  Haemoglobin,  .90 -f.  Urine 
normal.  The  Roentgen  rays  gave  an  encouraging  picture 
of  improvement  in  the  partially  luxated  knee. 

On  January  loth  Prof.  Keen  stretched  the  legs  under 
ether,  and  with  such  good  results  that  in  a  week  she  was 
able  to  stand  on  crutches^  and  unaided  to  walk  a  few  steps. 

I  think  we  may  now  feel  assured  that,  if  no  intercur- 
rent accident  occurs,  this  patient  wall  regain  such  health 
of  mind  and  body  as  will  repeat  the  extraordinary  results 
of  the  very  similar  case  of  Miss  C,  already  alluded 
to,  and  more  fully  recorded  in  my  Lectures  on  the 
Xervous  Diseases  of  Women. 

I  have  thought  it  well  to  give  unusually  ample  notes 
of  this  later  record  of  hysteria.  Xo  more  instructive 
lesson  can  be  given  as  to  the  need  for  hopeful,  persever- 
ing treatment  in  a  case  of  what  did  seem  at  first  beyond 
all  human  aid. 


CHAPTEE    XVII. 

HYSTERICAL  CONTRACTURES  {Continued). 

I  DISMISSED  last  week  a  case  of  contracture  in  which 
the  legs  were  in  extension.  I  read  you  the  notes  as  an 
interesting  contrast  to  the  flexor-spasms  just  described. 
I  like  also  to  speak  of  this  case  because  it  illustrates  one 
very  rational  way  of  dealing  with  a  partially  developed 
hysteria,  for  really,  despite  a  long  history,  it  was  unde- 
veloped. A  year  or  so  more  at  home  would  have  given 
us  another  bed-case. 

Case  LXV. — Annie  P.,  unmarried,  white,  seventeen 
years  of  age,  was  sent  to  rae  for  treatment,  and  was  admitted 
to  the  Infirmary  November  3,  1894.  The  family  history 
was  negative.  She  had  four  brothers  and  five  sisters 
who  were  living  and  well.  The  patient  was  a  small  child 
at  birth,  but  always  enjoyed  good  health.  She  had  the 
ordinary  diseases  of  childhood,  and  a  mild  typhoid  fever 
and  attacks  of  influenza  in  1890,  1891,  and  May,  1892. 
After  partial  recovery  from  the  last  attack  she  suddenly 
began  to  suffer  from  pain  in  the  right  heel  and  the  arch  of 
the  foot,  with  a  feeling  as  of  a  "  large  stone  in  the  shoe." 
Hot  water  gave  relief.  The  pain  returned,  and  was  now 
better  and  again  worse.  The  heel,  and  indeed  the  whole 
foot,  and  later  the  calf  and  the  outer  side  of  the  thigh, 
became  very  sensitive  to  touch,  and  were  also  the  seat  of 
much  spontaneous  pain.  Later,  pain  appeared  in  the  left 
heel  and  spread  similarly. 

About  one  year  after  the  first  attack  the  girl  was  sud- 
denly seized  with  acute  and  severe  pain  in  the  sacrum, 


276  NERVOUS  DISEASES. 

Avhicli  soon  affected  the  whole  spine.  Motion  of  the  arms 
and  legs,  she  said,  made  the  pain  worse.  She  now  took  to 
her  bed  (May,  1893).  Soon  afterward  she  became  rigid, 
with  the  arms  spread  out  laterally,  the  head  retracted,  and 
the  legs  extended.  Pain  was  then  severe  in  all  the  extrem- 
ities, but  not  alone  in  the  shortened  muscles.  It  gradually 
grew  less  toward  evening,  but  the  rigidity  continued.  The 
patient  was  never  unconscious.  During  the  summer  of 
1893  she  recovered  sufficiently  to  walk  a  little,  but  she  still 
had  great  back-pain  and  frequent  relapses. 

In  October,  1893,  after  walking  ''too  far,"  she  was  given 
a  hot  bath.  When  taken  out  she  fainted  and  had  ''heart- 
failure."  and  frequent  trouble  with  her  heart  afterward. 
She  was  almost  constantly  on  a  bed  or  sofa  from  that  time, 
and  had  occasional  attacks  of  asthma  during  the  year 
before  coming  under  observation.  Menstruation,  regular 
and  painless  before  the  present  trouble,  was  still  fairly  reg- 
ular, but  the  flow  was  very  dark  and  offensive,  though  quite 
free.  Otherwise  there  were  no  signs  of  disease  of  the 
genito-urinary  organs.  The  appetite  was  fair,  considering 
the  very  long  confinement.  Digestion  was  good.  The 
bowels  were  costive. 

Examination  showed  a  shghtly  built,  anaemic-looking 
girl,  weighing  eighty-three  pounds.  She  was  very  much 
emaciated,  especially  in  the  legs.  The  growth  of  hair  Avas 
unusual  and  excessive  for  her  age  and  sex,  all  over  the  body 
as  well  as  on  the  head.  The  skin  was  in  good  order,  and 
the  nails  smooth  and  well  formed.  All  touch  anywhere  on 
the  legs  and^feet  was  painful,  especially  on  the  inner  aspects. 
This  sensitiveness  varied  from  time  to  time,  A  slight  touch 
was  painful ;  pressure  excessively  so.  The  nerve-trunks 
seemed  no  more  tender  than  the  muscles.  Two  points  were 
nowhere  distinguished  as  such  on  the  feet  at  less  than  an 
inch  and  a  half,  and  at  a  slightly  less  distance  on  the  legs. 
The  temperature-sense  was  normal.     The  abdomen  was  not 


HYSTERICAL  CONTRACTURES.  277 

sensitive,  and  there  were  no  hysterogenic  areas  in  the 
ovarian  regions,  nor  any  typical  disturbance  of  the  color- 
fields. 

The  girl  was  without  pain  in  the  arms.  There  was  ap- 
parently a  slight  thickening  about  the  spinous  processes  in 
the  lower  dorsal  region,  and  the  processes  were  excessively 
sensitive.  The  whole  spine  and  the  gutter  on  both  sides 
for  a  distance  of  an  inch  and  a  half  or  two  inches  was  very 
tender,  with  areas  of  exquisite  hypersensitiveness  between 
the  shoulders,  at  the  waist,  and  over  the  whole  sacrum. 
Firm  pressure  with  the  palm  of  the  hand  over  the  sacrum 
was  less  painful  than  touch.  Use  of  the  arms,  she  said, 
increased  the  spinal  pain  and  tenderness.  The  knee-jerk 
was  slightly  increased,  and  easily  reinforcible  by  motion, 
sensation,  and  emotional  excitement.  There  was  no  clonus. 
Elsewhere  the  muscular  and  all  other  reflexes  were  normal. 
A  presystolic  murmur  was  heard  at  the  base  of  the  heart 
and  along  the  left  side  of  the  sternum,  and  faintly  in  the 
axilla  and  at  the  apex.  The  pulse,  which  was  soft  and 
wanting  in  fulness  and  force,  varied  from  100  to  120. 
Respiration  varied  from  30  to  50.  The  blood-count  was 
2,500,000  ;  the  color  75  per  cent. 

It  is  rare  to  see  so  great  sensitiveness  to  touch  as 
Miss  P.  exhibited,  and  still  more  rare  to  find  the  mus- 
cular tissue  sensitive.  As  to  contracture,  the  condition 
found  was  rare  and  curious.  The  extensors  and  flexors 
of  the  lower  limbs  all  felt  firm,  but  the  result  of  this 
general  contraction  was  rigid  stiffening  of  both  legs  in 
extension.  The  feet  were  less  remarkably  stiffened 
than  the  legs.  The  arms  were  no  longer  in  a  state  of 
contracture.  All  efforts  to  flex  and,  after  flexion,  to 
extend  the  legs  met  with  that  continuous  yielding 
resistance  common  in  spastic  states,  and  to  which  long 
ago  I  gave  the  name  of  ^'  lead-pipe"  symptom. 

24 


278  NF^P^  VO  US  DISEASES. 

At  my  secoDcl  visit  I  ordered  the  girl  to  walk,  and, 
despite  her  disbelief  in  her  power  to  obey,  she  was  able 
with  small  help  to  get  up  and  take  a  dozen  steps,  during 
which  the  heels  did  not  touch  the  floor.  Two  years  on 
bed  or  couch  made  this  exertion  difficult.  Having  once 
given  her  reason  for  hope,  I  put  her  back  in  bed,  and  for 
two  weeks  forbade  exercise,  while  massage,  tonics,  and 
good  diet  were  employed.  She  gained  rapidly  in  flesh. 
The  corpuscular  blood-count  doubled  after  a  week  of 
massage  •/  all  the  functions  began  to  resume  their  orderly 
action.  She  was  then  allowed  as  a  favor  to  rise  and  walk, 
and  two  weeks  later  was  able  to  go  home  in  excellent 
condition. 

In  the  present  case  I  began  by  insisting  that  this 
bedridden  girl  should  walk.  I  showed  her  that  she 
could  do  so,  and  promised  her  that  the  pains  in  the 
back  and  leg  would  leave  as  she  grew  more  and  more 
able  to  exercise.  Had  I  failed  as  to  my  predictions  I 
should  have  doubly  injured  the  case,  but  when  one  has 
had  a  long  experience  with  hysteria  it  is  easy  to  select 
the  cases  for  abrupt  exercise  of  authoritative  influence. 
There  were  doubts  and  tears,  but  she  walked,  as 
ordered. 

There  is  much  to  dwell  upon  in  the  several  cases  I 
have  brought  before  you.  But  now  it  is,  above  all,  the 
prognosis  and  treatment  to  which  I  desire  to  call  atten- 
tion. Charcot  has  said  that  very  marked  decrease  of 
faradic  contractility  ought  to  make  us  suppose  that  the 
spinal  cord  has  been  invaded,  and  that  the  existence  of 
a  spinal  organic  lesion  of  more  or  less  gravity  will  be 
placed  almost  beyond  doubt,  if,  under  the  influence  of 

1  See  paper  by  John  K.  Mitchell  on  the    Influence  of  Massage  on  the 
Blood-count     American  Journal  of  the  Medical  Sciences,  1894. 


HYSTERICAL  CONTRACTURES.  279 

deep  sleep  induced  by  chloroform,  rigidity  of  the  mem- 
bers only  gives  way  slowly,  or  even  persists  to  any 
marked  extent,  or  if  with  this  the  faradic  reactions  are 
greatly  lessened. 

You  will  have  seen  that  I  do  not  altoo^ether  ao;ree 
with  this  great  student  of  disease,  and  that  I  approach 
these  cases  in  a  far  more  hopeful  mood  than  I  could 
do  if  I  accepted  the  despair  which  his  dictum  would 
bring. 

The  treatment  need  hardly  be  set  forth  in  detail. 
Above  all,  get  your  hysteric  patient  away  from  her 
audience.  A  hospital-ward  is  no  place  for  her.  But 
if  you  cannot  deal  with  her  elsewhere,  treat  the  case  as 
commonplace  or  trivial,  and  call  no  attention  to  it. 
For  the  rest,  all  the  toning  means  are  of  use,  and  there 
are  moral  tonics  not  to  be  neglected,  but  for  which  a 
prosperous  hour  must  be  chosen. 

It  is  well  to  say  that  the  more  you  can  improve  the 
nutrition  of  joint,  muscle,  and  nerve  by  mechanical 
and  electric  tonics,  the  better  will  be  your  chances  of 
success  when  at  last  section  of  tendons  becomes  de- 
sirable. 

I  have  put  aside  a  final  case  of  contracture  in  the 
male  because  of  the  doubts  I  long  entertained  as  to  its 
origin. 

Case  LX  VI. — W.  H.  G.,  aged  thirty-three  years,  an  un- 
married railroad-clerk,  was  sent  to  me  by  Dr.  W.  S.  Beebe, 
of  Kirkwood,  N.  Y.  Dr.  J.  E.  Talley  has  made  the  fol- 
lowing notes  of  his  case :  The  man's  father  is  living  and 
well.  His  mother  died  of  typhoid  fever  at  fifty-seven  years 
of  age.  He  has  one  sister,  in  good  health.  There  are  no 
known  family  diseases  worthy  of  record.  The  patient  him- 
self   had    the  ordinary   diseases  of    childhood,   excepting 


280  ^ER  VO  us  DISEA  SES. 

scarlet  fever.  He  had  pneumonia  at  nine  years  of  age. 
He  never  drank  to  excess,  nor  has  he  ever  abused  the 
tobacco-habit.     He  certainly  has  had  no  syphilis. 

The  series  of  ailments  that  ended  in  \>  hat  you  see  began 
Tvith  bronchitis  in  1890.  His  physician  said  that  at  the 
time  he  T^as  run  down  from  overwork,  and  ordered  him  to 
take  a  vacation.  He  went  away  for  two  months  and  re- 
turned to  his  desk  feeling  much  better.  After  w^orking  for 
a  month,  he  was  on  November  6, 1890,  "seized  with  chills," 
and  had  three  in  succession.  After  this  he  was  confined  to 
bed  for  fourteen  weeks,  suffering  from  Avhat  w^as  described 
as  "nervous  prostration."  He  is  said  to  have  also  had 
some  bronchitis.  It  was  not  until  five  months  later  (April, 
1891)  that  he  was  out  of  bed  permanently,  and  able  to 
walk  with  the  aid  of  two  canes.  He  was  unsteady  on 
closing  his  eyes  and  when  trying  to  stand  or  walk  in  the 
dark.  At  this  time,  he  tells  us,  the  knee-jerk  was  present, 
and  this  is  probable,  as  the  patient  is  very  intelligent  and 
has  studied  his  symptoms  assiduously. 

During  1891  he  got  much  better,  and  walked  without  a 
cane,  except  when  going  a  long  distance.  He  still  con- 
tinued to  cough  more  or  less. 

In  March,  1892,  he  felt  w^ell  enough  to  go  down  to  El 
Paso,  Texas,  to  take  charge  of  an  office.  There  he  lost 
his  cough,  gained  in  weight,  and  was  doing  very  well  until 
August,  1893,  when  a  "very  dear"  friend  and  fellow-w^orker 
died  of  hiemoptysis.  The  shock  of  this  loss,  coupled  w^ith 
extra  work,  seemed  to  be  too  much  for  him,  and  again  he 
besran  to  fail,  and  to  become  on  the  least  occasion  emotional 
even  to  tears. 

From  September  1, 1893,  he  had  pains  in  his  feet,  which 
continued  until  December,  1893,  when  he  took  a  mustard 
foot-bath  for  their  relief.  On  the  following  morning  he 
awoke  to  find  his  legs  drawn  up  at  the  knees,  just  as  they 
were  w^hen  he  came  to  me  for  treatment  on  March  15, 1894. 


Hysterical  contractures.  281 

The  thighs  were  rigidly  drawn  up  so  as  to  touch  the  abdo- 
men. There  was  also  spastic  adduction  of  both  thighs  and 
of  the  legs  and  flexion  of  the  feet.  The  contractions  con- 
tinued to  become  more  complete  and  more  rigid.  As  to 
sensation  at  this  time  the  man  can  tell  us  as  to  this  nothing 
of  value. 

On  admission  to  the  Infi^rmary  the  contracted  and  sym- 
metrically wasted  state  of  the  lower  limbs  described  was 
very  apparent.  The  right  foot  was  flexed  firmly  against 
the  buttock,  a  forcible  pull  on  the  foot  being  required  to 
separate  the  heel  from  the  buttock.  The  left  foot  and  leg 
were  in  the  same  position,  except  that  the  heel  could  be 
separated  from  the  buttock  a  distance  of  a  foot  and  a  half 
by  force.  The  hamstring  tendons  on  both  sides  were  very 
rigid,  as  were  also  the  muscles  of  the  thigh  and  leg  on  both 
sides.  He  could  move  the  toes  of  both  feet  fairly  well,  but 
flexion  and  extension  at  the  ankles  were  limited,  every 
muscle  being  rigid. 

The  patient  said  that  the  wasting  of  the  limbs  was  really 
not  great,  as  he  had  always  been  very  thin.  The  circum- 
ference at  the  middle  of  the  right  thigh  was  35  cm.,  of  the 
left  35 i  cm.,  at  the  middle  of  the  legs  on  both  sides  10  cm. 
The  whole  body  was  extremely  emaciated.  The  hands 
showed  notable  wasting  of  the  interossei  muscles  and  of  the 
thenar  and  hypothenar  eminences.  There  was  no  clubbing 
of  the  fingers.  The  dynamometer  registered  oo  in  either 
hand.  The  spinal  column  showed  nothing  abnormal.  There 
were  scars  of  previous  cauterization. 

Sensation  was  everywhere  normal  until  we  examined  the 
feet.  In  the  left  foot  sensation  as  to  touch,  pain,  and  tem- 
perature was  absent  on  the  whole  dorsum,  the  anterior  third 
of  the  sole,  and  the  heel.  The  mid-region  recognized  touch. 
On  the  right  foot  there  was  an  absence  of  sensation  on  the 
first,  fourth,  and  fifth  toes  ;  touch  was  felt  in  the  third  and 
fourth  toes  on  both  surfaces ;  also  on  the  dorsum  and  on 

24^ 


282  NER  VO  US  DISEASES. 

the  sole  generally,  except  at  the  heel.  It  was  nowhere 
normal  on  either  foot,  but  improved  above  the  ankle  until 
at  mid-leg  it  seemed  perfect. 

These  facts  are  interesting,  because  there  is  no  account 
of  early  loss  of  feeling.  It  seems  certain,  however, 
that  this  anaesthesia  must  have  been  an  early  symptom. 
The  overwhelming  pain  appears  to  have  turned  atten- 
tion from  the  merely  negative  sign,  loss  of  tactile  sen- 
sation. 

Pain  had  been  felt  in  the  legs  before  contraction  came 
on,  but  was  never  severe,  and  was  taken  to  be  rheuma- 
tism. The  pain  which  came  after  the  contractions  had 
lasted  fifteen  days  w^as  more  severe  and  of  a  different 
character.  It  grew  to  be  at  last  the  absorbing  feature 
of  the  case. 

There  have  been  no  bedsores  or  evidences  of  grave 
trophic  disorder.  Co-ordination  was  good  in  the  arms  and 
fingers.  Station  and  gait,  of  course,  were  not  obtainable, 
the  man  being  bedridden,  nervous,  and  very  emotional. 

The  knee-jerk  was  not  obtainable,  nor  could  Ave  get  ankle- 
clonus  or  muscle-jerks  in  the  legs.  The  epigastric,  abdom- 
inal, and  cremasteric  reflexes  appeared  to  be  normal,  as 
was  also  the  elbow-jerk.  The  man  has  never  had  inconti- 
nence of  urine.  He  has  had  no  priapism ;  and,  in  fact, 
very  seldom  has  an  erection.  He  has  had  throughout  per- 
fect control  over  the  rectum. 

Dr.  Archibald  G.  Thomson  reported  upon  the  eyes : 
"  The  pupils  are  equal  and  dilated.  They  react  in  accom- 
modation, but  not  to  light.  The  media  are  clear.  The 
discs  are  a  trifle  grayish,  the  arteries  small.  The  fundus 
is  pale.  The  muscular  balance  is  good.  There  is  no  re- 
versal or  contraction  of  the  color-fields." 

With  the  man  on  his  back  the  chest-expansion  was  Ik 
inches.     The  percussion-note  was  higher-pitched  above  the 


HYSTERICAL  CONTRACTURES.  283 

right  than  above  the  left  clavicle,  and  a  full  inspiration 
heightened  the  pitch  on  the  right  side  and  but  very  little 
on  the  left.  The  whole  right  side  mov^ed  less  than  the  left. 
Respiration  was  a  trifle  harsh  at  the  left  apex,  and  expira- 
tion was  here  prolonged  and  more  marked  than  inspiration, 
but  of  about  the  same  pitch  as  elsewhere.  There  was  very 
little  change  in  vocal  fremitus  and  resonance  on  the  left 
side,  but  on  the  right  chest  anteriorly  the  voice  was  con- 
veyed much  more  clearly  than  elsewhere.  On  full  inspira- 
tion there  were  moist  rhonchi  at  both  apices,  more  marked 
on  the  right.  Posteriorly  the  eleventh  rib  on  the  left 
showed  a  prominence,  as  if  it  had  been  broken. 

On  having  the  patient  sit  np  it  was  observed  that  the 
left  nipple  was  slightly  higher  than  the  right.  The  right 
chest  moved  more  (2"  inch)  than  the  left  during  respiration. 
A  musical  murmur,  systolic  in  time,  was  heard  at  the  end 
of  expiration  over  the  base  and  at  the  apex  of  the  heart. 
The  apex-beat  was  found  to  be  in  the  fourth  interspace, 
with  the  greatest  impulse  at  the  sterno-costal  junction. 

Staining  the  sputum  for  tubercle-bacilli  was  negative ; 
nranalysis  also  was  negative.  The  temperatures  w^ere  rarely 
over  the  normal  line. 

It  was  evident  that  the  lung-condition  had  nothing 
to  do  with  the  paralysis.  There  was  much  difference 
of  opinion  as  to  the  cause  of  these  very  interesting  con- 
tractures. The  absence  of  a  more  distinct  previous 
hysterical  history  led  some  of  our  staff  to  regard  the 
case  as  possibly  one  of  spinal  hemorrhage. 

As  to  treatment  I  had  no  indecision.  The  great 
flexion  of  the  thigh  on  the  pelvis,  as  in  Miss  C.'s  case, 
kept  the  sciatic  nerve  stretched  at  the  notch.  There 
was  but  one  remedy.  As  to  what  more  we  should  win 
beside  relief  from  pain  I  could  not  anticipate. 


284  NER  VO  US  DISEASES. 

At  my  desire,  on  March  29, 1894,  Dr.  W.  W.  Keen  oper- 
ated on  the  right  leg,  dividing  the  thigh-muscles  at  their 
attachments  to  the  pelvis ;  also  the  inner  and  outer  ham- 
string tendons.  He  could  not  bring  the  leg  to  a  straight 
position  even  then  on  account  of  the  rigidity  of  the  parts, 
and  for  fear  of  tearing  the  contracted  femoral  vessels. 
The  limb  was  dressed,  and  a  double-inclined  plane  and  ex- 
tension-weights applied.  The  extension-apparatus  slowly 
accomplished  its  purpose,  but  was  somewhat  hampered  by 
the  development  of  a  small  bedsore  over  the  sacrum  as  a 
result  of  the  necessity  of  keeping  the  man  constantly  on 
his  back.  This  soon  healed,  and  the  limb  was  then  more 
actively  extended  each  day  by  increasing  the  weights. 

As  this  extension  at  once  eased  and  soon  put  an  end  to 
pain  in  the  foot  of  the  leg  on  which  Dr.  Keen  had  oper- 
ated, it  was  thought  well  to  treat  the  other  limb  in  like 
fashion.  This  was  done  on  June  19,  1894,  with  equally 
good  results. 

The  surgical  treatment  closed  with  section  of  both  gas- 
trocnemial  tendons  on  December  7,  1894.  The  patient 
has  now  no  pain,  and  has  gained  from  day  to  day  and 
month  to  month  in  the  straightening  of  the  limbs,  in  moral 
courage,  and  in  increasing  freedom  from  nervousness. 

Except  for  an  attack  of  diphtheria,  which  necessitated 
removing  the  man  to  the  Municipal  Hospital,  where  he 
stayed  from  December,  1894,  until  January  22,  1895,  he 
has  been  making  constant  improvement.  His  present  state 
(February  4,  1895)  is  as  follows : 

A  faint  systolic  murmur  is  heard  over  the  apex  of  the 
heart  and  at  the  base.  Xo  circulatory  disturbance  exists. 
The  lungs  have  cleared  up.  There  is  no  cough  or  expec- 
toration. The  blood-count  is  4,900,000.  The  hsemoglobin- 
value  of  the  blood  is  95  per  cent.,  and  the  man  looks  ruddy. 
There  is  an  absence  of  the  neurotic  facies.  The  muscles  are 
less  wasted,  but  firm,  and  respond  well  to  the  faradic  cur- 


HYSTERICAL  CONTRACTURES.  285 

rent  everywhere,  even  in  the  legs.  There  are  no  tender 
spots  on  the  body  and  there  is  no  evidence  of  neuritis. 
The  man  controls  his  bowels  and  urine  normally.  There 
is  no  priapism  or  other  abnormality  of  the  genital  organs. 
The  weight  to-day  is  101  i  pounds,  being  a  gain  of  only 
6f  pounds  since  admission  to  the  wards. 

There  is  still  general  emaciation,  but  the  thighs  and  legs 
are  somewhat  more  wasted  than  other  parts  of  the  body. 
There  are  to  be  seen  the  scars  of  the  operations  on  the 
thighs  and  legs.  There  are  no  excoriations,  no  clubbing  of 
the  nails,  or  other  evidences  of  trophic  disturbance  other 
than  those  caused  by  lack  of  use  of  the  muscles. 

The  right  thigh  is  in  a  straight  line  with  the  abdomen 
as  the  patient  lies  on  his  back.  The  leg  can  be  extended 
to  an  angle  of  170°  with  the  thigh.  The  right  ankle  is 
perhaps  a  little  extended,  the  toes  being  slightly  flexed. 

The  left  thigh  is  also  in  a  straight  line  with  the  abdomen, 
as  is  the  left  leg  with  the  thigh  as  the  man  lies  passively  on 
the  bed.     The  ankle,  foot,  and  toes  are  in  good  position. 

Both  thighs  can  be  freely  flexed,  adducted,  and  circum- 
ducted, and  there  is  the  same  voluntary  control  over  the 
knees,  legs,  and  ankles.  The  toes  are  less  freely  movable. 
The  man  walked  five  feet  with  the  assistance  of  the  nurse 
and  a  chair  to-day.  The  grasp  is  good  and  equal,  and  no 
other  motor  palsy  exists. 

The  patient  has  taken  tonics,  cod-liver  oil,  etc.,  and  since 
September  17,  1894,  he  has  had  massage  and  movements 
with  faradism  daily  to  the  affected  limbs. 

Early  in  April  Dr.  William  J.  Taylor  divided  the  mus- 
cles on  the  inner  side  of  both  feet.  This  was  needed  be- 
cause of  the  swelling  and  pain  in  the  feet  when  the  man 
was  long  afoot,  and  which  seemed  due  to  the  cramped  form 
of  these  parts. 

On  May  11,  1895,  the  man  was  walking  a  little  on 
crutches    and   improving.      After  exercise    the  feet  were 


286  ^EB  VO  US  DISEASES. 

still  more  or  less  painful.     He  has  steadily  grown  better 
up  to  this  date  (June,  1895). 

The  case,  as  you  have  heard  it,  does  not  enable  us  to 
be  sure  as  to  the  immediate  cause  of  the  trouble.  G. 
has  been  asthenic — neurasthenic,  if  you  please;  he  re- 
covers, goes  South,  and,  as  a  railway  clerk,  is  overtaxed 
and  much  worried.  For  ten  days  he  has  aches  in  the 
legs,  and  awakens  at  last  with  his  legs  drawn  up. 

Are  these  hysterical  contractures?  At  first  they 
could  be  relaxed  under  ether.  Must  we  accept  Char- 
cot's dictum  that  this  is  a  certain  sign  of  their  hysterical 
origin  ?  There  was  probably  some  early  loss  of  sensa- 
tion, but  if,  as  has  been  suspected,  these  spasms  w^ere 
due  to  a  hemorrhage  within  or  on  the  cord,  we  might 
well  have  had  this  symptom.  I  confess  that  there  was 
too  little  disturbance  to  allow  me  to  entertain  the  latter 
diagnostic  theory.  Here  is  a  man  wdio  sleeps  well  and 
awakens  with  great  and  increasing  contractions,  and 
probably  with  more  or  less  anaesthesia.  In  time  the 
reflexes  fail  or  lessen;  the  electric  reactions  are  quanti- 
tatively diminished,  and  the  mechanical  reactions  lost. 
All  this  might  come  from  a  neurotic,  functional  spasm, 
and  it  all  reads  like  the  progressive  story  of  an  hyster- 
ical disorder.  It  differs  in  no  w^ise  from  the  cases  of 
Miss  C.  and  Miss  H.,  except  that  there  are  no  other 
hysterical  signals  flying.  Also  in  this  (G.)  case  the 
reflexes  have  come  back,  the  electric  reactions  are  all 
better,  and  here  and  there  we  can  call  out  movement 
by  a  blow  with  the  hammer.  At  present  G.'s  legs  are 
straight,  or  nearly  so,  and  the  muscles  are  all  improv^- 
ing.  Where  and  when  these  gains  will  end  I  do  not 
know;  but  certainly  so  far,  in  the  light  of  treatment. 


HYSTERICAL  CONTRACTURES.  287 

the  case  does  not  read  like  one  of  orgauic  disease  of 
the  cord,  nor  like  any  form  of  neuritis. 

My  conclusion  is  that  in  this  case  we  have  hysterical 
contractions  in  the  adult  male,  a  rare  phenomenon,  in 
this  country  at  least,  where  we  have  the  nervous  tem- 
perament, but  are  not  neurotic  to  the  extent  seen  in  the 
Latin  races. 

Fortunately,  cases  of  general  contracture  are  rare. 
But,  whether  general  or  local,  if  they  have  proved 
during  four  or  five  months  amenable  to  no  medical 
means,  then  I  counsel  the  use  of  the  knife  and  the  sec- 
tion of  tendons.  It  is  true  that  Charcot  and  others 
have  described  cases  in  which,  after  years,  contractions 
ceased  abruptly  and  the  limb  was  as  before.  The  state- 
ment should  have  had  a  long  appendix  of  exceptions. 
In  cases  of  moderate  contracture,  not  drawing  the  part 
to  an  extremely  acute  angle,  sudden  recovery  may  leave 
the  joints  undamaged ;  but  in  grave  cases  this  never 
can  be  the  case  with  joints  like  the  knee,  which  is 
always  the  most  difficult  articulation  to  deal  with.  A 
long,  violent  contraction  of  the  flexors  partly  luxates 
the  tibia  backward,  and  results  in  joint-changes  which, 
after  years  of  contraction,  are  incapable  of  cure. 

In  these  knee-cases,  perhaps  in  all  articulations  long 
out  of  place,  there  is  probably  soon  or  late  more  or  less 
of  that  kind  of  inflammation  which  is  also  seen  in  joints 
too  long  on  a  splint.  If  this  be  so,  a  part  of  the  quan- 
titative failures  to  respond  to  electricity  may  be  due  to 
the  muscular  wasting  so  commonly  observed  in  connec- 
tion with  damaged  joints. 

But,  whatever  the  cause,  I  have  seen  hysterical  con- 
tractions in  which,  after  section  of  tendons,  the  joints 
were  too  much  altered  to  admit  of  useful  restoration. 


288  NER  VO  US  DISEASES. 

The  leg,  bent  at  an  angle  of  45°,  is  brought,  by  section 
and  the  screw,  to  a  much  larger  angle,  but  cannot  be 
made  straight  enough  for  use.  There  is  motion  within 
limits,  but  with  weak  muscles  and  beut  legs  the  effort 
needed  for  walking  becomes  excessive.  Under  these 
circumstances  there  may  arise  a  question  as  to  the  pro- 
priety of  making  the  leg  straight  by  an  operation  that 
will  leave  it  rigid.  Above  all,  I  wish  to  impress  upon 
you  finally  that  a  long-contractured  limb  is  not  a  limb 
to  confide  to  the  rare  relief  brought  or  not  brought  by 
time. 

I  desire  to  call  attention  to  certain  hitherto  un- 
noticed clinical  facts  : 

1.  Two  forms  of  hysterical  contracture  exist.  One 
concerns  single  parts  and  limited  groups  of  muscles. 
In  this  the  contracture  may  last  for  years  w^ithout  the 
addition  of  organic  changes  in  muscles,  joints,  or  inter- 
stitial tissues.  In  this  variety,  or  species,  if  you  like, 
of  the  genus  contracture,  sudden  cessation  of  the  spasm 
is  possible,  or  more  probable  than  in  generalized  con- 
tractures. 

2.  Another  form  of  contracture  exists  which  attacks 
in  succession  one  limb  after  another,  until  soon  or  late 
all  or  nearly  all  the  voluntary  muscles  of  the  limbs, 
as  well  as  those  of  the  trunk,  may  become  involved. 
The  cases  of  this  group  do  not,  in  my  experience,  ever 
get  well  abruptly.  In  them  the  muscles,  joints,  and 
areolar  tissues  undergo  serious  organic  changes. 

In  the  first  or  limited  form  the  muscles  and  the  mus- 
cular reflexes  remain  unaltered  or  are  but  little  changed, 
and  mechanical  and  electric  responses  continue  to  be 
normal  or  nearly  so.  In  the  second  or  generalized 
form  the  muscle-muscle-reflexes,  such  as  knee-jerk,  are 


HYSTERICAL  CONTRACTURES.  289 

lost  or  mechanically  interfered  with  late  in  the  dis- 
order, and  the  electric  responses  are  quantitatively  les- 
sened, and  may,  in  time,  be  almost  altogether  lost.  It  is 
only  in  this  form,  after  years  of  life  in  bed,  that  we 
may  expect  to  see  changes  in  the  cord.  Whether  these 
are  merely  independent  accidents,  or  are  the  rare  sec- 
ondary products  of  the  hysterical  condition  or  of  the 
organic  changes  this  occasions  in  the  peripheral  nerves 
and  muscles,  we  do  not  yet  know. 

In  both  forms  we  may  expect  to  find  loss  in  the 
sensory  function  of  the  skin,  and  more  surely  in  the 
generalized  contracture. 


25 


CHAPTEK    XVIII. 

ROTATORY    MOVEMENTS    IN   THE    FEEBLE-MINDED. 

Most  people,  when  seated,  find  some  vague  relief  in 
change  of  attitude.  Evea  when  lying  at  rest  in  bed 
we  still  feel  this  need;  long-continuance  in  one  position 
seems  to  make  it  agreeable  to  alter  it. 

In  some  persons  an  excess  of  this  tendency  is  shown 
in  constant  restlessness;  with  some,  and  especially 
among  children,  it  exists  remarkably  during  sleep. 
Certain  persons  incline  to  repeat  one  movement,  and 
find,  in  so  doing,  the  comfort  most  of  us  obtain  from 
any  change  of  posture.  The  frequent  repetition  of  a 
movement  may  end  in  its  becoming  masterful,  and 
finally  the  habit  may  gain  almost  despotic  control. 

The  young  are,  naturally,  the  most  liable  to  become 
the  victims  of  such  tricks  of  habit.  If  they  are  prop- 
erly cared  for  as  children,  they  soon  unlearn  these  mor- 
bid ways;  or,  if  uncared  for,  they  may  carry  them  into 
adult  life. 

The  acts  I  refer  to  may  be  very  simple  movements, 
but  sometimes  they  are  or  come  to  be  complicated 
motions,  the  origin  and  continuance  of  which  it  is  not 
easy  to  understand.  I  knew  a  man  who  carried  out  of 
childhood  a  curious  habitual  action.  Always  before 
sitting  down  he  walked  once  around  the  chair.  If  by 
any  chance  he  forgot  to  do  so,  he  must  rise  and  obey 
the  impulse.  He  was  ashamed  of  this  habit,  and  would 
loiter  and  move  about  to  conceal  the  action,  but  always 


ROTATOR  Y  MO  VEMENTS.  291 

must  at  last  go  once  around  the  chair.  Another 
person,  a  woman,  sat  down  only  to  rise,  and  sit, 
and  so  on,  a  dozen  times  before  she  could  remain  at 
ease. 

Somewhere  on  the  boundary  line  between  voluntary 
and  involuntary,  or,  rather,  automatic  acts,  lie  the  move- 
ments seen  in  the  disorder  I  named  habit-chorea  or, 
as  others  like  to  call  it,  habit-spasm.  In  this  a  child 
is  subject  to  movements  of  one  or  another  set  of  mus- 
cles, and  these  are  more  or  less  capable  of  control.  It 
is  a  morbid  condition,  and  usually  curable. 

Whatever  the  source  of  any  of  these  movements,  it 
is  repetition  which  finally  gives  to  them  the  power  of 
a  habit.  At  last  to  arrest  such  movement  by  force  of 
will  becomes  difficult.  A  vast  sense  of  relief  arises 
when  we  yield  to  the  tendency  to  repeat  a  habitual 
motion.  Increasing  discomfort  attends  upon  the  refusal 
to  obey  the  habit-born  impulse.  I  have  seen  a  girl's 
arm  tied  to  the  waist  by  a  mother  resolute  to  break  up 
the  habit  of  rubbing  the  top  of  her  head;  a  violent 
attack  of  hysteria  followed. 

:::  In  some  cases  the  smaller,  simpler  habit-acts  are 
more  easy  to  overcome  than  are  the  larger  and  compli- 
cated movements,  like  the  spinning  habit. 

If  the  whole  range  of  these  semi-automatic  or  impul- 
sive movements  is  to  be  found  in  the  ranks  of  the 
healthy,  it  seems  obvious  that  in  the  mentally  defec- 
tive, a  class  indifferent  to  criticism  and  with  less  will- 
force  at  command,  we  should  find  them  in  their  most 
despotic  forms.  Indeed,  in  the  young  of  imperfect 
mind  these  habit-acts  are  apt  very  soon  to  become  im- 
perative.     I  fancy  they  are  often  semi-imperative  from 


292  NEB  VO  US  DISEASES. 

the  start,  and  are  the  offspring  of  suggestion  or  inher- 
ited instincts. 

Among  the  defective  who  are  found  at  Elwyn^  are 
numerous  illustrations  of  many  varieties  of  the  forms 
of  movement  of  which  I  have  briefly  spoken.  At 
present  I  desire  to  ask  attention  especially  to  the  rare 
cases  of  Dervish  movement,  which  I  hesitate  to  de- 
scribe as  spasm  without  further  knowledge  of  how  far 
these  acts  were  primarily  irresistible  or  how  far  they 
have  become  so  from  frequent  repetition.  It  is  con- 
ceivable that  in  the  slackly  governed  organization  of  a 
defective  child  these  motor  habits  in  which  a  certain 
pleasure  is  found  may  arise  and  dominate  far  more 
readily  than  in  those  of  sound  mind. 

The  cases  I  shall  relate  differ,  and  each  must  be 
studied  by  itself.  I  have  myself  seen  elsewhere  two 
cases  of  tendency  to  spin  in  which  the  children 
were  in  perfect  health  of  body  and  mind;  both 
were  girls.  When,  in  one  of  these  cases,  the  mother 
realized  that  an  ungovernable  habit  had  been  formed, 
the  child,  then  about  ten  years  old,  was  brought  to 
me  for  advice.  At  first  the  girl  had  merely  rotated 
until  giddy,  as  many  children  like  to  do.  Finding 
some  satisfaction  in  it,  she  took  to  rotating  when 
alone,  and  at  last  became  remarkably  expert.  She 
confessed  that  she  liked  it,  and  would  go  where, 
unnoticed,  she  could  spin  unseen.  By  this  time  the 
habit  had  become  so  despotic  that  when  kept  with 
other  and  older  people  she  would  jump  up  of  a  sudden 
and  spin  furiously  until  she  was  forcibly  stopped. 
When  long  controlled  she  became  strangely  restless, 
and,  if  allowed  a  minute's  spin,  seemed  to  be  at  once 

1  The  Pennsylvania  Institution  for  Feeble-minded  Children. 


ROTA  TOR  Y  MO  VEMENTS.  293 

comforted.  This  child  was  easily  cured  by  a  long  stay 
ia  bed.  There  were  no  evidences  of  hysteria,  and  it 
was  most  unlike  the  case  of  hysterical  gyration  which 
I  have  elsewhere  related. 

Defective  children  or  adults  who  rotate  evidently 
derive  a  certain  amount  of  enjoyment  from  their  aston- 
ishing feats,  whether  the  motion  be  the  imperative 
result  of  organic  disease  or  only  a  habit  long  undis- 
turbed by  disciplinary  or  other  interference.  There  is 
also  added  the  distinctive  satisfaction  obtained  by  the 
weak-minded  when  able  to  attract  observation  or  to 
excite  surprise. 

Case  LXVII. — L,  H.,  female,  aged  sixteen  years,  came 
to  the  Pennsylvania  Training  School  for  Feeble-minded 
Children  from  the  almshouse.  The  maternal  grandparents 
were  intemperate.  The  father  was  also  a  drunkard  and 
abused  the  mother  before  conception  and  during  preg- 
nancy. There  are  two  other  children  living,  a  boy  and  a 
girl — the  latter  is  an  inmate  of  the  Elwyn  School ;  a  sister 
died  at  eleven  months  in  convulsions. 

The  patient  was  born  at  term ;  labor  was  normal.  She 
was  nourished  at  the  breast  three  months  by  the  mother, 
and  then,  strange  to  say,  seven  months  by  the  maternal 
grandmother.  She  was  a  sickly  baby,  and  had  convulsions 
from  the  fifth  until  the  eighth  month  of  life,  but  has  had 
none  since. 

In  late  childhood,  but  exactly  when  is  unknown,  Dervish 
spinning,  as  described  below,  appeared. 

She  is  now  a  small,  pale-faced  child.  No  palsies,  no  atro- 
phies. Teeth  fair.  No  signs  of  septic  taint.  Heart  and 
lungs  normal.  All  bodily  functions  are  performed  nor- 
mally. She  has  not  yet  menstruated.  Her  vocabulary  is 
small  and  her  speech  is  somewhat  indistinct.     She  is  active, 

25* 


294  NEE  VO  US  DISEASES. 

noisy,  and  heedless  of  danger.  She  is  also  nervous  and 
restless.  She  is  destructive  and  dangerous  as  to  fire,  and 
is  apt  to  stray  from  the  Home.  She  attends  the  school, 
and  understands   readily  what  is  said  to  her  and  obeys 

Fig.  17. 


promptly,  but  her  physical  and  mental  restlessness  is  so 
great  that  she  cannot  improve  much  in  school-work. 

The  station  with  eyes  open  or  shut  is  good.     Knee-jerk 
normal.     The  pupils  are  equal  and  react  to  light  and  Avith 


ROTA  TOR  Y  MO  VEMENTS.  295 

accommodation.  Sensation  is  normal,  and  there  are  no 
physical  deformities.  She  has  occasionally  some  involun- 
tary twitchings  of  the  face. 

The  most  interesting  symptom  in  her  case  is  the  habit  of 
Dervish  spinning.  Many  times  daily  she  suddenly  rises, 
walks  to  the  middle  of  the  room,  rests  upon  one  heel 
(usually  the  left  one),  the  toes  being  raised,  and  then 
rotates,  usually  to  the  left,with  extreme  rapidity,  her  dress 
rising  like  the  governor  of  a  steam  engine,  as  shown  in  Fig. 
17  ;  her  arms  are  either  clasped  upon  the  chest  or  widely 
extended,  and  her  right  foot  beats  the  floor  to  keep  up 
the  rotation.  While  spinning,  her  place  on  the  floor 
changes  but  little ;  there  is  almost  no  forward,  backward, 
or  lateral  progress.  The  duration  of  the  spinning  varies 
from  fifteen  minutes  to  a  half-hour.  There  is  usually  no 
acceleration  of  her  normal  pulse  (90)  or  of  respiration 
(20).  While  rotating,  her  eyes  remain  closed.  There  is 
no  evidence  of  vertigo.  She  is  able  after  a  half-hour's  spin 
to  walk  away  on  a  perfectly  straight  line.  There  is  no 
evidence  that  she  is  under  the  influence  of  any  imperative 
impulse,  nor  are  the  movements  forced.  It  seems  like  a 
natural  act.  If  in  good  humor,  she  will  spin  or  cease  to 
spin  at  command ;  if  in  bad  humor,  she  will  refuse  to 
obey  either  request.  When  asked  why  she  spins,  she 
answers  (and  her  intelligence  is  sufficiently  to  be  relied 
upon)  that  she  "  likes  it;  it  is  fun."  Her  sister  will,  if 
requested,  go  through  the  same  movements,  but  does  them 
clumsily. 

When  seen  by  me  after  thirty  minutes'  spinning  her 
pulse  had  risen  from  90  to  115,  but  the  respiration  did 
not  rise  in  like  proportion.  When  asked  to  spin  to  the 
right  she  tries  it,  but  is  unable  to  do  it  with  ease  or  as  long 
as  she  is  able  to  rotate  to  the  left.  The  motion  is  so  in- 
conceivably rapid  that  two  of  us  failed  to  count  the  rate 
of  the  spin. 


296  NERVOUS  DISEASES. 

Case  LXVIII.— H.  F.  was  admitted  to  the  Pennsyl- 
vania Training  School  for  Feeble-minded  Children  from 
the  almshouse  on  May  30,  1877,  when  five  years  of  age. 
He  was  healthy  when  born,  but  at  four  months  of  age  he 
fell  twelve  feet  and  had  spasms  from  that  time  ;  occasion- 
ally they  lasted  for  two  weeks.  Tiie  mother  was  born  in 
Ireland  ;  the  father  was  a  native  of  Philadelphia.  There 
were  two  healthy  children,  younger  than  the  one  here 
spoken  of.     Paternal  grandfather  was  insane. 

The  patient  was  small  of  stature,  light  weight,  and  a 
demi-microcephalic,  an  epileptic,  and  a  mute  idiot.  He 
had  general  convulsions  three  or  four  times  a  month. 

The  boy  is  interesting  or  remarkable  only  for  his  automa- 
tism, which  existed  when  he  was  admitted.  At  all  times 
he  was  subject  to  odd  motions  of  the  hands,  but  periodi- 
cally during  the  day  he  would  give  an  exhibition  of  the 
habit,  which  has  given  him  the  name  of  "  The  Dervish." 
This  began  with  tapping  his  chin  with  his  left  hand,  deli- 
cately and  rapidly,  touching  the  fingers  of  his  left  hand  to 
the  wrist  of  the  right,  making  two  or  three  salaams,  after 
which  he  began  to  gyrate  from  the  left  to  the  right.  The 
right  heel  acted  as  a  pivot,  and  the  rotation  was  kept  up 
by  touches  of  the  left  toe  or  heel  to  the  floor.  The  turns 
varied  from  three  to  seven,  with  intervals  of  a  salaam  or 
two  between  every  set  of  rotations,  and  lasted  for  a  long 
while.  Fifteen  minutes  or  more  were  thus  passed  before 
he  darted  away  toward  a  window,  where  he  remained  a 
few  minutes  in  a  fixed  or  dazed  state,  from  which  he 
aroused  to  recommence  his  hand  tricks,  perhaps  liking  to 
stand  on  a  broad  belt  of  sunlight,  so  as  the  better  to  dis- 
play his  hand,  which  he  watched  with  some  appearance  of 
enjoyment.  He  suffered  from  cataract  of  the  right  lens, 
and  possibly  partial  amaurosis  of  the  left  eye. 

A  supplemental  performance  was  to  stand  in  one  place 


ROTA  TOR  Y  310  VEMENTS.  297 

and  throw  the  head  and  shoulders  from  side  to  side,  de- 
scribing with  the  forearm  two-thirds  of  a  circle,  with  the 
occiput  set  back  as  far  as  the  neck  would  permit.  In 
none  of  these  performances  was  it  thought  that  conscious- 
ness was  abolished  or  suspended. 

He  seldom  lost  his  balance  and  could  walk  very  straight 
the  moment  he  stopped  spinning.  He  has  been  known  to 
make  2000  revolutions  in  an  hour. 

In  1886  he  seemed  to  be  failing,  and  became  too  weak 
to  spin.  About  this  time  he  became  almost  blind — quite 
so  in  one  eye.  The  only  improvement  noticed  in  the  effort 
to  train  him  was  that  his  habits  were  more  cleanly.  His 
hearing  was  very  acute.  He  could  distinguish  voices  in  a 
crowd  when  there  was  a  great  deal  of  noise,  and  he  would 
respond  when  a  familiar  voice  called  him  by  name.  His 
head  was  inclined  almost  constantly  to  the  left.  He 
seemed  to  have  an  idea  of  self-preservation,  though  he 
appeared  oblivious  of  what  was  going  on  around  him.  He 
died  in  a  spasm  on  October  14, 1890.  The  spasms  were 
always  unilateral,  and  alternated,  first  on  the  right,  then 
on  the  left  side. 

Post-mortem  examination.  Body  well  nourished,  skull 
normal,  demi-microcephalic,  scalp  very  thick.  Dura 
mater  so  firmly  adherent  to  the  skull-cap  along  superior 
longitudinal  sinus  that  the  sinus  was  torn  open  on  remov- 
ing the  bone.  Right  hemisphere  fairly  well  developed  and 
apparently  healthy.  On  the  left  side  the  occipital  lobe 
was  entirely  destroyed,  as  w^as  also  the  left  anterior  one 
and  part  of  the  superior  parietal  and  supramarginal  lobe  ; 
a  thick-walled  cyst  supplied  their  place.  The  left  tem- 
poral lobe  was  hard,  white,  and  shrunken.  The  remaining 
portions  of  the  hemisphere  exhibited  the  atypical  arrange- 
ment of  the  convolutions  often  seen  in  brains  where  devel- 
opment has  been  interfered  with  very  early  in  life.    Hemi- 


298  ^'ER  VO  us  DISEASES. 

opia  must  in  this  case  have  existed  since  the  origin  of  the 
lesion. 

This  case  I  never  saw.  I  am  indebted  for  the  notes 
to  Dr.  ^I.  AY.  Barr,  the  physician  in  charge  of  the 
Elwyn  Asylum. 

The  motions  were  probably  imperative,  but  even  as 
to  so  plain  a  case  of  organic  disease  it  is  difficult  to  feel 
secure  as  to  this  point.  It  is  not  stated  that,  like  the 
last  case,  the  eyes  were  kept  shut  while  he  rotated,  nor 
is  the  rate  of  motion  given.  It  is  said  to  have  been 
very  rapid. 

Case  LXIX. — Male,  aged  thirty-two  years.  This  man 
is  a  medium-grade  imbecile.  His  station  and  gait  are 
steady.  Knee-jerks,  pupillary  and  other  reflexes  are 
present.  There  are  no  sensory  or  motor  disturbances. 
He  is  robust  and  works  continuously  under  the  guidance 
of  an  attendant.  There  is  no  deformity  of  head,  spine, 
or  extremities.  The  thoracic  and  abdominal  viscera  pre- 
sent no  symptoms  or  physical  signs  of  disease.  Scars  on 
the  chest  and  back  are  suggestive  of  syphilis,  but  there  are 
no  distinct  evidences  of  the  condition.  The  tongue  is  clean 
and  protrudes  straight,  and  there  are  a  few  scars  upon  this 
organ,  the  result  of  injury  during  previous  epileptic  fits. 
His  sight  and  hearing  are  good  and  he  talks  quite  readily, 
but  his  answers  to  questions  are  somewhat  incoherent  and 
wandering.  He  seems  of  mild  disposition,  but  is  subject  to 
outbursts  of  temper,  which  may  come  on  abruptly.  There 
are  no  fixed  hallucinations. 

When  working  or  while  eating  he  suddenly  stands  up 
and  turns  once  around  slowly ;  then  he  sits  down  or  goes 
about  his  occupation  with  an  air  of  apparent  mental  relief. 
He  never  turns  to  the  right,  and  the  motion  was  not  re- 
produced at  suggestion. 


ROTA  TOR  Y  MO  YEMEN TS.  299 

This  patient  is  intelligent  enough  to  tell  me  that  he 
is  unable  to  resist  the  impulse  to  rise  and  turn  around 
as  described.  When  asked  to  get  up  and  turn  he  re- 
fused to  do  so ;  but  after  a  time,  which  was  variable, 
he  leaped  up  of  a  sudden,  turned  once,  or  even  twice 
(which  is  rare),  and  then  quietly  resumed  his  work. 
Occasionally  while  walking  he  executes  the  same  single 
rotatory  motion,  and  then  moves  on  as  before. 


INDEX 


ALLEN,  PROF.,  operation  bv 
258 
Anaemia,  pernicious,  133,  142 
Anpesthesia,  hysterical,  281 

psychic.  17 
Anatomy  of  sciatic  tract,  159 
Anhaloninm,  symptoms  of,  61 ' 
Anosmia,  19 

Anxiety  of  prse-dormitium,  67 
Arthritis  in  hemiplegia,  146 
in  hysterical  disease,  287 
Ataxia,  cerebellar  cause  of,  130 
Gowers  on,  131 
hysterical,  142 

on  awakening,  87 
motor,  in  a  child,  125 
muscle  sense  in,  137 
pernicious  anaemia  and,  133 
retained  reflexes  in,  137 
Aura,  visual,  84 

with  sensory  shocks,  81 


BAILLARGER  on    hallucina- 
tions of  pree-dormitium,  60, 
61 
Ball,  Dr.  M.  V.,  32 
Barr,  case  by,  298 
Bennett  on  sensory  auras,  83 
Blindness,  hysterical,  253 

psychic,  15 
Blood-letting  in  melancholia,  47 
Briquet  on  hysterical  ataxia,  141 
Bromide   causing   homicidal  im- 
pulses, 63 
Burr,  case  by,  182 

on  local  temperature-changes 

from  position,  207 
post-mortem  notes  by,  143 


/RATLIN  on  relation  of  pain  to 
\J     weather,  162 
Childbed  causing  sciatica,  157 
Chorea,  eye-examination  in,  227 

hysterical,  94 

in  sleep,  85,  86,  87 

of  habit,  96 

on  waking,  87,  89 
Clark  on  eye-strain,  224   ■ 
Cold -sensations,    cases    of,    115- 
117 

causes  of,  111 

classification  of.  107 

from  neuritis,  120 
of  Cauda,  117 

hysterical,  122 

in  buttocks,  112,  113 

intensified   capacity  to    feel, 
121 

Mills  on,  124 

of  central  origin,  108,  111 

Putnam  on,  123 

subjective,  in  peripheral  neu- 
ritis, 112 

with   elevation  of  tempera- 
ture, 113,  117 

with     unchanged     tempera- 
ture, 112 
Color-fields  in    hysterical   para- 
plegia, 35,  75 

normal,  in  hysteria,  270,  282 

reversal  of,  106 
Contracture,  hysterical,  242,  275 

anaesthesia  in,  261,  266 

cases,  249,  275,  279     ^ 

diflfering  forms  of,  246,  2S8 

ending  in  sclerosis,  243 

multiple,  of  hysteria,  244 

painful,  281 


26 


302 


IXDEX. 


Contracture,  probably  not  spinal 
in  origin,  248 
reflexes  in,  245 
reflexes  absent  in,  266 
resembling      poliomyelitis, 

246 
Richet  on,  247 
symptomatolog}'  of,  243 
tenotomy  for,  24S,  284 
Cooper,  Sir  Astley,  110 
Cuba,  seasonal   melancholia   in, 

43 
Curvature,  spinal,  with  insanity, 
210 
cases,  212  215,  216 

DAY-NUMBNESS  functional. 
68 
Deafness,  hysterical,  253 
Derby  on  e^ve-strain,  221 
De  Schweinitz,   eve-examination 
by,  20,  96,  138,  190,  214 
eyes  in  chorea,  227 
on  sleep-ptosis,  77,  78 
Diaphragm,    spasm    of,    in    hys- 
teria, 253 
Dyer  on  eye-strain,  221 
Dysaesthesia  on  waking,  70 
Dyschromatopsia,  hysterical,  75, 
106 
in  hysterical  palsies,  36 
J.     K.      Mitchell     and     de 
Schweinitz  on,  36 

EPILEPTICS,  eyes  of,  227 
Erythromelaigia,  177 

blood-pressure  in,  195 
cases  of,  178,  181,  185, 

197 
compared     with      Ray- 
naud's disease,  179 
incurability  of,  190 
morphia  in,  197 
surface-temperature    in, 

197 
with  gangrene  of  foot, 

197 
with  sciatica,  172 
Examination,     post-mortem,     of 
spinning  case,  297 


Eve-strain  as  cause  of  headaches, 

'220 
Eyes  in  chorea,  227 
in  epilepsy,  227 

FAILURE,  respiratory,  in  sleep, 
91 
Feeble-minded,    rotatory    move- 
ments in,  290 
Fere,  cases  by,  73,  75 
Foot-fidgets,  86 

GERHARDT  on  erythromelai- 
gia, 180 
Glycosuria  in  melancholia,  51 
Gowers  on  ataxia,  131 


HABIT-CHOREA,  96 
diet  in,  98 
eyes  in,  227 
treatment  of,  98 
Hall,    Dr.    P.    S.,    post-mortem 

notes  by,  203 
Hallucinations  of  prpe-dormitium, 

62 
Headaches  and  eye-strain,  220 
Heat-sense,  loss  of,  2')6 
Hemianopsia,  hysterical,  20 
Hemiplegia,  arthritis  in,  146,  150 
nocturnal,  68 
node  in,  150,  151 
nodes  following.  145, 149 
pain  as  a  prodrome  of,  143 

as  a  sequel  of,  143 
subjective  coldness  in,  111 
Hewson   on   anatomy   of    sciatic 

tract,  159 
Hip-disease   simulating   sciatica, 

158 
Hurd  on  recurrent  melancholia, 

42 
Hyperaesthesia.  hysterical,  276 
Hypnotism  in  melancholia,  34 
Hysteria,  anaesthesia  in,  281 
ataxia  of,  87.  142 
contracture  in,  242,  279 

multiple  in,  244 
dyschromatopsia  in,  35,  75, 

'106 
eyes  in,  35,  75,  106,  270,  282 


INDEX. 


303 


Hysteria,  myoclonus  in,  99 
sclerosis  following,  248 
sensations  of  cold  in,  122 
with  locomotor  ataxia,  133 

IMPULSE,    homicidal,    due   to 
1  bromides,  63 

in  melancholia,  46 
Insanity,  relation  of  pra?-dormi 

tium  to,  59 
Insomnia  from  eve-strain,  223 


J 


ACKSOX,    Professor   Samuel, 
on  recurrent  melancholia, 


on     respiratory     failure     in 
sleep,  91 
Joints,    post-hemiplegic    disease 
of,  148,  150 


KEEN  and  Morehouse  on  pain- 
misreference,  233 
operation  by,  192,  270,  284 
Kinnicutt,  case  by,  120 
Knee-jerk,  in  ataxia,  131 
in  sclerosis,  132 
reinforcement  of,  132 
Krafft-Ebing,    melancholic   hyp- 
notized by,  34 

LANNOIS  on  erythromelalgia, 
179 
Leg -pain  in  sleep,  79 

MELANCHOLIA,    abrupt    re- 
covery in,  26,  37 
bloodletting  in,  48 
caused  by  dream,  50 
during  digestion,  51 
effect  of  menstruation  on,  44 
heredity  in,  28 
inter-menstrual,  47 

case  of,  44 
irregular  recurrent,  53 
menstrual,  44,  AQ 
of  post-dormitium,  49 
predisposing  causes,  27 
recurrent  seasonal,  32 


Melancholia,  recurrent  seasonal, 
cases  of,  32,  36.  37,  39,  40 
related  to  sleep,  49 
removal  of  ovaries  in,  45 
sensory  delusions  during  post- 
dormitium,  49 
tends  to  recur,  31 
treated  by  hypnotism,  34 
with  erotic  impulses,  45 
with  glycosuria,  51 
with  homicidal  impulse;  46 
Melancholies,  marriage  of,  29 
Mills  on  cold-sensations,  124 
Mind-blindness,  15 
Misreference  of  pain,  231 
Mitchell,  J.  K.,  and  de  Sclnveinitz 

on  dyschromatopsia,  36 
Mitchell,  J.  K..  on  misreference 
of  pain,  234 
joint-lesions  from  spinal  in- 
juries, 145 
Morton,  operation  by,  159,  202 
Movement-rate  in  ataxia,  138 
Movements,  imperative,  291 
rotatorv,  290 
spinning,  292,  293,  296 
Myoclonus,  multiple,  99,  100 
Muscle,   pyriform,    share   of,    in 
producing  5-ciatica,  160 
-sense  in  ataxia,  137 


^AUSEA  from  eye-strain,  223 
xi     Neuritis  as  a  cause  of  ery- 
thromelalgia, 181, 194, 
196 
changes  of  tnermal  sense 

in,  120 
cold-sensations  in,    112, 

117,  120 
sciatic,  155 
terminal,  194 
Neuroses,  ocular,  220 
Nodes  following  hemiplegia,  145, 

149,  151 
Numbness,  hysterical,  73 


OCULAK  neuroses,  220 
Olfaction,  loss  of,  19 
Ormerod  on  numbness,  72 


304 


INDEX. 


PAIN  and  weather,  Catlin  on, 162 
as  a  prodrome  of  hemiplegia, 
145,147 
Pain  as  a  sequel  of  hemiplegia, 
147 
misreferred,  231 

cases,  231,  233,  234 
Paralysis  from  irritation,  76 

hysterical,  266 
Paraplegia,  hysterical,  35 
Paresis,  nocturnal,  68,  72,  75 
Pearce  on  local  temperatures,  207 
Pershing,  case  by,  15 
Pinel  on   seasonal  melancholia, 

42 
Post-dormitium,  59 

relation  of,  to  insanity,  59 
sensory  delusions  in  melan- 
cholia, 49 
Prse-dormitium,  Baillarger  on,  60 
hallucinations  in,  62 
olfactory  disturbance  in,  62 
relation  of,  to  insanity,  59 
sensory  shocks  in,  83 
terrors  in,  6o 
Pregnancy,    delusion   of,   in    the 
insane,  239 
spurious,  236 
Prentiss  on  physiological  effects 

of  anhalonium,  61 
Pseudocvesis,  236 

cases,  236,  237,  238,  239,  241 
causation  of,  239 
Hirst  on,  238 

sympathetic  vomiting  of  hus- 
band in,  241 
vomiting  in,  238 
Ptosis  of  sleep,  77 
Putnam  on  cold-sensations,  123 


RANNEY,  on  eye-treatment  of 
epilepsy,  228 
Raynaud's  disease,  case  of,  178 

compared  with  erythro-  ; 
melalgia,  177,  179         I 
Reactions,  faradic,  in  hysterical 
paralysis,  278,  279        '  | 

Reaction-time  in  ataxia,  138,  139 
Reflex  ocular  neuroses,  220  I 

Reflexes  retained  in  ataxia,  128     \ 


Reinforcement  of  knee-jerk,  132 
Richet  on  contractiires,  247 
Rigidity,  hysterical,  on  a\vaking, 

90 
Rotation,  imperative,  298 
Rotatory  movements,  290 

cases  of,  293,  296,  297 


SAUNDBY  on  sleep-numbness, 
68 
Schiile,  on  recurrent  melancholia, 

43 
Sciatica,  154 

and  erythromelalgia,  172 

cases  of,  169,  170,  171 

childbed,  157 

diagnosis  of,  154 

double,  170 

from     fecal     accumulations, 

156 
from  pelvic  growth,  156 
from  pressure  during  deliv- 
ery, 156 
from  tumor,  159 
hours  of  exacerbation,  161 
influence  of  position  on,  158 
of  central  origin,  175 
pyriform  muscle's  share  in, 

*160 
simulated   by  hip-joint   dis- 
ease, 158 
treatment  of,  164 
bandage,  166 
blisters,  167 
cautery,  167 
cocaine,  165 
dry  cups,  165 
ice,  167 
massage,  167 
morphine.  165 
nerve  stretching,  175 
splint-rest,  165 
Sciatic  nerve,  anatomy  of,  159 
Sclerosis,  knee-jerk  in,  132 

post-hysterical,  248 
Sensory  shocks,  80 
Sharkey  on  misreference  of  pain, 

232  " 
Shocks,  auditory,  81 

and  sensory,  81 


INDEX. 


305 


Shocks,  olfactory,  81,  83 
sensory,  80,  81 

in  daytime,  83 
visual,  81 
Sinkler  on  numbness,  72 
Sleep  disorders,  58 
-jerks,  85 
-numbness,  68 

in  neuritis,  71 
with  pain,  71 
-pain,  79 
-ptosis,  77,  78 
respiratory  failure  in,  91 
-shocks  80,  82 

double  auras  in,  84 
prne-dormitium,  80 
olfactory,  83 

aura  in, 84 
visual  aura  in,  84 
Smith,  I)r   Andrew  H.,  on  sleep- 
numbness,  68 
Spasm,  tonic,  on  waking,  89,  90 
Stevens  on  refractive  lesions,  225 
Surface-temperatures,  205,  207 
Starr,  case  by,  37 
Syphilis,  sciatica  due  to,  156 


Tenotomy  for  hysterical  contrac- 
ture, 272 
in  ocular  neuroses,  229 
Thermometer  for  surface-temper- 
atures, 205 
Thermometry    of    erythromelal- 

gia,  201 
Thomson  on  astigmatism  causing 
headache,  226 
A.  G.,  eye-examinations  by, 
128,  267,  282 
Tobacco  causing  sleep-jerks,  86 

-shocks,  82 
Tyrell  on  eye-strain,  224 


UREA  lessened  in  acute  melan- 
cholia, 56 


yASO-MOTOR  paralysis  of  ex- 

T      tremities,  177 
Vertigo  from  eye-strain,  223 
Vomiting,  sympathetic,    in    hus- 
band, 241 
Visual-fields  in  hysteria,  36,  75, 
106 


TIAYLOR,  J    M.,  case  by,  169 
1  170 

on     anomalous     sciatic 
nerve^  159 
W.  J.,  operation  by,  285 
Temperature,  difference  of,  on  two 
sides,  206 
influence  of  position  on,  207 


WAKING-NUMBNESS,  70 
cases  of,  72,  75 
following    nerve  -  freez- 
ing, 71 
Waking  tonic  spasm,  89 
Weather  and  pain,  162 
Witmer  on  reaction-time,  138 


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CLINICAL.  The  Section  on  Embryology  by  Prof.  Milnes  Mar- 
shall. In  one  large  octavo  volume  of  872  pages,  with  231  illustra- 
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BARTHOIiOW  (ROBERTS).  CHOLERA;  ITS  CAUSATION,  PRE- 
VENTION AND  TREATMENT.  In  oue  12mo.  volume  of  127  pages, 
with  9  illustrations.     Cloth,  $1.25. 

BARTHOIiOW  (ROBERTS).  MEDICAL  ELECTRICITY.  A 
PRACTICAL  TREATISE  ON  THE  APPLICATIONS  OF  ELEC- 
TRICITY TO  MEDICINE  AND  SURGERY.  Third  edition.  In 
one  octavo  volume  of  308  pages,  with  110  illustrations. 

BELL  (F.  JEFFREY).  COMPARATIVE  ANATOMY  AND  PHYS- 
IOLOGY. In  one  12mo.  volume  of  561  pages,  with  229  engravings. 
Cloth,  $2.     See  Students'  Series  of  Manuals,  p.  14. 

BELLAMY  (EDWARD).  A  MANUAL  OF  SURGICAL  ANATOMY. 
In  one  12mo.  vol.  of  300  pages,  with  50  illustrations.     Cloth,  $2,25. 

BERRY  (GEORGE  A.).  DISEASES  OF  THE  EYE  ;  A  PRACTICAL 
TREATISE  FOR  STUDENTS  OF  OPHTHALMOLOGY.  Second 
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illus.  in  the  text,  of  which  87  are  exquisitely  colored.     Cloth,  $8. 

BILLINGS  (JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY. 
Including  in  one  alphabet  English,  French,  German,  Italian  and 
Latin  Technical  Terms  used  in  Medicine  and  the  Collateral  Sciences. 
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AND  PATHOLOGICALLY  CONSIDERED.  In  one  12mo.  volume 
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BLOXAM  (C.  L.).  CHEMISTRY,  INORGANIC  AND  ORGANIC. 
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In  one  handsome  octavo  volume  of  727  pages,  with  292  illustrations. 
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BROADBENT  (W.  H.).  THE  PULSE.  In  one  12mo.  vol.  of  317  pages, 
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KOCH'S  REMEDY  IN  RELATION  ESPECIALLY  TO  THROAT 

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BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY, 
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macy, the  Physiological  Action  and  the  Therapeutical  Uses  of  Drugs. 
In  one  octavo  volume. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo  vol, 
of  1040  pa^es,  with  727  illustrations.     Cloth,  $6,50 ;  leather,  $7.50. 

BUMSTEAD  (F.  J.)  AND  TAYLOR  (R.  W.).  THE  PATHOLOGY 
AND  TREATMENT  OF  VENEREAL  DISEASES,  See  Taylor  on 
Venereal  Diseases,  page  15. 

BURNETT  (CHARLES  H.).  TPIE  EAR :  ITS  ANATOMY,  PHYSI- 
OLOGY AND  DISEASES.  A  Practical  Treatise  for  the  Use  of 
Students  and  Practitioners.  Second  edition.  In  one  8vo.  volume  of 
580  pages,  with  107  illustrations.     Cloth,  $4 ;  leather,  $5. 

BUTLIN' (HENRY  T.).  DISEASES  OF  THE  TONGUE.  In  one 
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PRIXCIPLES  OF  HUMAN  PHYSIOLOGY.    In  one  large  octavo 

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CARTER  (R.  BRUDEXELiL)  AND  FROST  ( W.  ADA3IS).  OPH- 
THALMIC SURGERY.  In  one  pocket-size  12mo.  volume  of  559 
pages,  with  91  engravings  and  one  plate.  Cloth,  $2.25.  See  Series  of 
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CASPARI  (CHARLES  JR.).  A  TREATISE  OX  PHARMACY. 
For  Students  and  Pharmacists.  In  one  handsome  octavo  volume  of 
680  pages,  with  288  illustrations.     Cloth,  $4.50. 

CHA3IBERS  (T.  K.).  A  MAXUAL  OF  DIET  IN  HEALTH  AND 
DISEASE.     In  one  handsome  8vo.  vol.  of  302  pages.     Cloth,  $2.75. 

CHAPMAN  (HENRY  C).  A  TREATISE  OX  HUMAX  PHYSI- 
OLOGY. In  one  octavo  volume  of  925  pages,  with  605  illustrations. 
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CHARLES  (T.  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIO- 
LOGICAL AXD  PATHOLOGICAL  CHEMISTRY.  In  one  hand- 
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CHEYNTE  (AV.  WATSON).  THE  TREATMENT  OF  WOUNDS, 
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CHURCHnjL  (FLEETWOOD).  ESSAYS  OX  THE  PUERPERAL 
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CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).  THE  DISSECTOR'S 
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Cloth,  $1.50.     See  Students^  Series  of  3Iamuxls,  p.  14. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF 
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CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  14. 

CLOUSTON  (TH03IAS  S.).  CLINICAL  LECTURES  ON  MENTAL 
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.■<5.50  f  )r  the  two  works. 

CLOWES  (FRANK).  AX  ELEMENTARY  TREATISE  ON  PRACTI- 
CAL CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALY- 
SIS. From  the  fourth  English  edition.  In  one  handsome  12mo,' 
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COATS  (JOSEPH).  A  TREATISE  OX  PATHOLOGY.  In  one  vol. 
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COLEMAN  (ALFRED)."  A  MAXUAL  OF  DEXTAL  SURGERY 
AXD  PATHOLOGY.  With  Xotes  and  Additions  to  adapt  it  to  Amer- 
ican Practice.  By  Thos.  C.  Stellwagen,  M.A.,  M.D.,  D.D.S.  In  one 
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CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
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one  large  8vo.  volume  of  719  pages.     Cloth,  .$5.25  ;  leather,  $6.25. 

CORNTL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNO- 
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J.  Henry  C.  Simes,  M.D.  and  J.  William  White,  M.D.  In  one 
8vo.  volume  of  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CULBRETH  (DAVID  M.  R.).  MATERIA  MEDICA  AND  PHAR- 
MACOLOGY. In  one  handsome  octavo  volume  of  812  pages,  with 
445  illustrations.     Cloth,  .$4.75.     Just  ready. 

CULVER  (E.  M.)  AND  HAYDEN  (J.R.).  MANUAL  OF  VENE- 
REAL DISEASES.  In  one  12mo.  volume  of  289  pages,  with  33 
engravings.     Cloth,  $1.75. 


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DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.  In 

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DAVENPORT  (F.  H.).  DISEASES  OF  WOMEN.  A  Manual  of 
Non-Surgical  Gynecology.  For  the  use  of  Students  and  General  Prac- 
titioners. Second  edition.  In  one  handsome  12mo.  volume  of  314 
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DAVIS'  (EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  FOR 
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octavo  volume  of  54(3  paa:es,  Avith  217  engravings  and  30  full-page 
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DAVIS  (F.  H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition.     In  one  12mo.  volume  of  287  pages.     Cloth,  $1.75. 

DB  IjA  BECHE'S  geological  OBSERVER.  In  one  large  octavo 
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DENNIS  (FREDERICS.)  AND  BILLINGS  (JOHN  S.).  A  SYS- 
TEM OF  SURGERY.  In  contributions  by  American  Authors. 
Complete  work  in  four  very  handsome  octavo  volumes,  containing 
3652  pages,  with  1585  engravings  and  45  full-page  plates  in  colors  and 
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DERCUM  (FRANCIS  X.,  EDITOR).  A  TEXT-BOOK  ON 
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DE  SCHWEINITZ  (GEORGE  E.).  THE  TOXIC  AMBLYOPIAS. 
Their  Classification,  History,  Symptoms,  Pathology  and  Treatment. 
Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page 
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DRAPER  (JOHN  C).  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  volume 
of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF 
MODERN  SURGERY.  A  new  American,  from  the  twelfth  London 
edition,  edited  by  Stanley  Boyd,  F.  R.  C.  S.  In  one  large  octavo 
volume  of  965  pages,  with  373  engravings.     Cloth,  $4  ;  leather,  $5. 

DUANE  (ALEXANDER).  THE  STUDENT'S  DICTIONARY  OF 
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DISEASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.     Cloth,  3il.50. 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCI- 
ENCE. Containing  a  full  explanation  of  the  various  subjects  and 
terms  of  Anatomy,  Physiology,  Medical  Chemistry,  Pharmacy,  Phar- 
macology, Therapeutics,  Medicine,  Hygiene,  Dietetics,  Pathology,  Sur- 
gery, Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecol- 
ogy, Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  etc.,  etc. 
By  RoBLEY  DuNGLiSON,  M.  D.,  LL.  D.,  late  Professor  of  Institutes 
of  Medicine  in  the  Jefferson  Medical  College  of  Philadelphia.  Edited 
by  Richard  J.  Dunglison,  A.  M.,  M.  D.  Twenty-first  edition,  thor- 
oughly revised  and  greatly  enlarged  and  improved,  with  the  Pronuncia- 
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EDES   (ROBERT  T.).     TEXT-BOOK   OF  THEKAPEUTICS  AND 

MATERIA  MEDICA.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3.50 ; 
leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  A  Manual  for 
Students  and  Practitioners.  In  one  handsome  8vo.  volume  of  576  pages, 
with  14S  enirravinsrs.     Cloth,  +3  ;  leather,  $4. 

ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection. 
From  the  eighth  and  revised  English  edition.  In  one  octavo  volume 
of  716  pages^  with  249  engravings.     Cloth,  $4.25  ;  leather,  $5.25. 

EM1\IET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRAC- 
TICE OF  GYNAECOLOGY,  for  the  use  of  Students  and  Practitioners. 
Third  edition,  enlarged  and  revised.  In  one  large  8vo.  volume  of  880 
pages,  with  150  original  engravings.     Cloth,  .$5  ;  leather,  $6. 

ERICHSEN  (JOHN  E.^.  THE  SCIENCE  AND  ART  OF  SUR- 
GERY. A  new  American  from  the  eighth  enlarged  and  revised  Lon- 
don edition.  In  two  large  octavo  volumes  containing  2316  pages,  with 
984  engravings.     Cloth, "$9  ;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  Just  ready. 
See  American  Text-Books  of  Dentistry,  page  2. 

FARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Fourth  American  from  fourth  English  edition,  revised  by  Frank 
WoODBrRY,  M.  D.     In  one  12mo.  volume  of  581  pages.    Cloth,  $2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE 
EAR.  Fourth  edition.  In  one  octavo  volume  of  391  pages,  witii  73 
engravings  and  21  colored  plates.      Cloth,  $3.75. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE.  New  (7th)  edition,  thoroughly  revised 
by  Frederick  P.  Henry,  M  D.  In  one  large  8vo.  volume  of  1143 
pages,  with  engravings.     Cloth,  $5.00 ;  leather,  $6.00. 

A   MANUAL   OF   AUSCULTATION  AND  PERCUSSION ;  of 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson,  M.  D. 
In  one  handsome  12mo.  volume  of  274  pages,  with   12  engravings. 

A    PRACTICAL    TREATISE    ON     THE    DIAGNOSIS    AND 


TREATMENT  OF  DISEASES  OF  THE  HEART.  Second  edition, 
enlarged.     In  one  octavo  volume  of  550  pages.     Cloth,  $4. 

—  A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLO- 
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EASES AFFECTING  THE  RESPIRATORY  ORGANS.  Second 
and  revised  edition.     In  one  octavo  volume  of  591  pages.   Cloth,  $4.50. 

—  MEDICAL  ESSAYS.   In  one  12mo.  vol.  of  210  pages.  Cloth,  $1.38. 
ON  PHTHISIS  :  ITS  MORBID  ANATOMY,  ETIOLOGY,  ETC. 


A  Series  of  Clinical  Lectures.  In  one  8vo.  volume  of  442  pages. 
Cloth,  $3.50. 

FOLSOM  (C.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S. 
ON  CUSTODY  OF  THE  INSANE.  In  one  8vo.  vol.  of  108  pages. 
Cloth,  $1.50.  With  Clouston  on  Mental  Diseases  (new  edition,  see 
page  4)  $5.50  for  the  two  works. 

FOSTER  (MICHAELS.  A  TEXT-BOOK  OF  PHYSIOLOGY.  New 
(6th)  and  revised  American  from  the  sixth  English  edition.  In  one 
large  octavo  volume  of  923  pages,  with  257  illustrations.  Cloth,  $4.50 ; 
leather,  $5.50. 

FOTHERGILL  (J.  ^flLNER).  THE  PRACTITIONER'S  HAND- 
BOOK OF  TREATMENT.  Third  edition.  In  one  handsome  octavo 
volume  of  664  pages.     Cloth,  $3.75 ;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEM- 
ISTRY (INORGANIC  AND  ORGANIC).  Twelfth  edition.  Em- 
bodying Watts'  Physical  and  Inorganic  Chemistry.  In  one  royal 
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FRANKLAND  (E.)  AND  JAPP  (F.R.).  INORGANIC  CHEMISTRY. 

In  one  handsome  octavo  volume  of  677  pages,  with  51  engravings  and 
2  plates.     Cloth,  $3.75  ;  leather,  $4.75. 

FULLER  (EUGENE).  DISORDERS  OF  THE  SEXUAL  OR- 
GANS IN  THE  MALE.  In  one  very  handsome  octavo  volume  of 
238  pages,  with  25  engravings  and  8  full-page  plates.  Cloth,  $2. 
Just  ready. 

FULLER  (HENRY).     ON  DISEASES  OF  THE  LUNGS  AND  AIR 

PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.  From  second  English  edition.  In  one  8vo.  volume  of  475 
pages.     Cloth,  $3.50. 

GANT  (FREDERICK  JAMES).  THE  STUDENT'S  SURGERY.  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3.75. 

GLBBES  (HENEAGE).  PRACTICAL  PAl^HOLOGY  AND  MOR- 
BID HISTOLOGY.  In  one  very  handsome  octavo  volume  of  314 
pages,  with  60  illustrations,  mostly  photographic.     Cloth,  $2.75. 

GLBNEY  (V.  P.).  ORTHOPEDIC  SURGERY.  For  the  use  of  Practi- 
tioners and  Students.     In  one  8vo.  vol.  profusely  illus.     Preparing. 

GOULD  (A.  PEARCE).  SURGICAL  DIAGNOSIS.  In  one  12mo. 
vol.  of  589  pages.     Cloth,  $2.  See  StadenVs  Series  of  Manuals,  p.  14. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
New  and  thoroughly  revised  American  edition,  much  enlarged  in  text, 
and  in  engravings  in  black  and  colors.  In  one  imperial  octavo  volume 
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GRAY  (LANDON  CARTER).  A  TREATISE  ON  NERVOUS  AND 
MENTAL  DISEASES.  For  Students  and  Practitioners  of  Medicine. 
New  (2d)  edition.  In  one  handsome  octavo  volume  of  728  pages,  with 
172  engravintjs  and  3  colon d  plates.     Cloth,  $4.75;   leather,  $5.75. 

GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY 
AND  MORBID  ANATOMY.  New  (7th)  American  from  the  eighth 
London  edition.  In  one  handsome  octavo  volume  of  595  pages,  with 
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GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DIS- 
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BLADDER,  THE  PROSTATE  GLAND  AND  THE  URETHRA. 
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HABERSHON  (S.  O.).  ON  THE  DISEASES  OF  THE  ABDOMEN, 
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HAMILTON  (ALLAN  McLANE).  NERVOUS  DISEASES,  THEIR 
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HAMILTON  (FRANK  H.).  A  PRACTICAL  TREATISE  ON  FRAC- 
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HARDAWAY  (W.  A.).  MANUAL  OF  SKIN  DISEASES.  In  one 
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HARE  (HOBART  AMORY).  PRACTICAL  DIAGNOSIS.  THE 
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HniLiIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES. 
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HODGE  (HUGH  L.).  ON  DISEASES  PECULIAR  TO  WOMEN, 
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HUDSON  (A.).   LECTURES  ON  THE  STUDY  OF  FEVER.    In  one 

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JONES    (C.   HANDFIELD).       CLINICAL    OBSERVATIONS    ON 
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JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE 
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KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.     Shortly.     See 

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one  pocket-size   12mo.   volume  of  376  pages,  with   194  engravings. 
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LA  ROCHE  (R.).     YELLOW  FEVER.     In  two  ^vo.  volumes  of  1468 
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PNEUMONIA.     In  one  8vo.  volume  of  490  pages.     Cloth,  $3. 

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LAWSON  (GEORGE).  INJURIES  OF  THE  EYE,  ORBIT  AND 
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SUPERSTITION   AND   FORCE;  ESSAYS  ON  THE  WAGER 


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LEE  (HENRY)  ON  SYPHILIS.  In  one  8vo.  volume  of  246  pages. 
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LEISH3IAN  (\\TLLLI.M).  A  SYSTEM  OF  MIDWIFERY.  Includ- 
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LOOMIS  (ALFRED  L.)  AND  THO]\rPSON  (W.  OILMAN), 
EDITORS.  A  SYSTEM  OF  PRACTICAL  MEDICINE.  In 
Contributions  by  Various  American  Authors.  In  four  very  hand- 
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LUCAS  (CLEMENT).  DISEASES  OF  THE  URETHRA.  Preparing. 
See  Series  of  Clinical  3fanuals,  p.  13. 

LUDLOW  (J.  L.).  A  MANUAL  OF  EXAMINATIONS  UPON 
ANATOMY,  PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDI- 
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engravings.     Cloth,  $2.     See  Student's  Series  of  Manuals,  p.  14. 

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LYONS  (ROBERT  D.).  A  TREATISE  ON  FEVER.  In  one  octavo 
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MAISCH  (JOHN  iVL).  A  MANUAL  OF  ORGANIC  MATERIA 
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MANUALS.  See  Student's  Quiz  Series,  p.  14,  Student's  Series  of  Manu- 
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ings.    Cloth,  $1.75. 


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MITCHELL  (JOHN  K.).  REMOTE  CONSEQUENCES  OF  IN- 
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MtJLLER  (J.).  PRINCIPLES  OF  PHYSICS  AND  METEOROL- 
OGY.    In  one  large  8vo.  vol  of  623  pages,  with  538  cuts.  Cloth,  $4.50. 

MUSSER(JOHNH.).  A  PRACTICAL  TREATISE  ON  MEDICAL 
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NATIONAL  DISPENSATORY.  See  StilU,  Maisch  &  Caspari,  p.  14. 

NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  p.  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Fourth  American 
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OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN. 
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MENT.    In  one  octavo  volume  of  272  pages.    Cloth,  $2.50. 

PARVm  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OB- 
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677  pages,  with  267  engravings  and  2  colored  plates.  Cloth,  $4.25 ; 
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PAVY  (F.  W.).  A  TREATISE  ON  THE  FUNCTION  OF  DIGES- 
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second  London  edition.     In  one  8vo.  volume  of  238  pages.     Cloth,  $2. 

PAYNE  (JOSEPH  FRANK).  A  MANUAL  OF  GENERAL 
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cine. In  one  octavo  volume  of  524  pages,  with  153  engravings  and 
1  colored  plate.     Cloth,  $3.50. 

PEPPER'S  SYSTEM  OF  MEDICINE.     See  p.  2. 

PEPPER  (A.  J.).  FORENSIC  MEDICINE.  In  press.  See  Student's 
Series  of  Manuals,  p.  14. 

SURGICAL  PATHOLOGY.     In  one  12mo.  volume  of  511  pages, 

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PICK  (T.  PICKERING).  FRACTURES  AND  DISLOCATIONS. 
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PIRRIE  (WILLIAIM).  THE  PRINCIPLES  AND  PRACTICE  OF 
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12  Lea  Ckutiii:ks  &  Co.'s  ruiihiCAxioNs. 

pijAyfair  (w.  s.).    a  teeatise  ox  the  science  and 

PRACTICE  OF  MIDWIFERY.  Sixth  American  from  ihe  eighth 
English  edition.  Edited,  with  additions,  by  R.  P.  Harris,  M.  D. 
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POLITZER  ( AI>.\]>I).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE 
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748  pages,  with  330  original  engravmgs.     Cloth,  $5.50. 

POWER  (HENRY).  HUMAN  PHYSIOLOGY.  Second  edition.  In 
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See  Student's  Series  of  Manuals,  p.  14, 

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QUIZ  SERIES.     See  Student's  Quiz  Series,  p.  14. 

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Lea  Brothers  &  Co.'s  Publications.  13 


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14  Lea  Brothers  &  Co.'s  Publications. 


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WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
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YEAR-BOOK  OF  TREATMENT  FOR  1897.  A  Critical  Review  for 
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YEAR-BOOKS  OF  TREATMENT  FOR  1891,  1892,  1893  and  1896, 
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YEO  (I.  BURNEY).  FOOD  IN  HEATH  AND  DISEASE.  New 
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A   MANUAL   OF   MEDICAL  TREATMENT,  OR  CLINICAL 

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YOUNG  (JA]\IES  K.).  ORTHOPEDIC  SURGERY.  In  one  8vo. 
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